Why don't psychiatrists ask about abuse?

February 23, 2016 1:53 AM

I haven't been asked directly about my abuse and trauma history when meeting with mental health professionals. Is this standard? If so, why?

I was filling out forms for an appointment with a psychiatrist and noticed that, despite there being several dozen pages covering health and psychiatric history in great detail, there were no questions about abuse, trauma, or violence (except asking whether the patient had been violent). I ended up writing notes in an "other comments" field.

Thinking back, I don't remember the subject ever coming up in psychiatrist appointments at all. I could have brought it up more easily in therapy appointments, but I don't recall being asked directly there either, and that's one of the reasons I never felt comfortable talking about it. Is my experience more typical or unusual? If it is typical, is there a reason they're reluctant to ask, or is trauma maybe less relevant to mental illness than I think?

posted by fair isle sock to Health & Fitness (16 answers total)

Best answer: Could it be because this psychiatrist's model of mental illness is medical/biological rather than, e.g., biopsychosocial?

The mental health professions (psychoanalyst vs. psychiatrist vs. counsellor) tend to vary widely in their training, theories of mental distress and approach to treatment. Psychiatry is well-known for being the most devoted to the medical model (something is organically wrong with you = manage it with drugs) rather than a model that takes life events into account. I'm always struck by how devoted some mental health professionals are to constructing a narrative of mental distress that revolves around genetics and neurochemistry rather than, e.g., meaningful and distressing life events. I guess it's easier than confronting trauma and abuse.

This does NOT mean trauma is not relevant to mental illness. It just means that this particular psychiatrist may not consider it relevant.

disclosure: I am a therapist who embraces the biopsychosocial model.
posted by stuck on an island at 2:32 AM on February 23, 2016 [6 favorites]

On reading your question more closely, I see your history hasn't been addressed in therapy either. That's a shame. If you consider it relevant to your situation, it is definitely worth bringing up yourself, even if the practitioner doesn't.
posted by stuck on an island at 2:33 AM on February 23, 2016

Best answer: There's actually a movement within the mental health sector toward integrating trauma experiences into treatment and support (and making treatment and support safe for trauma survivors). It's called Trauma Informed Care. I work in mental health in Australia (not as a practitioner) and TIC is increasingly informing practice in community mental health organisations and even in some psych hospitals. I'm sorry you've had such crappy experiences with your support team. Searching for care providers who've done Trauma Informed Care training may give you better experiences.

(stuck on an island is right, psychiatry under the medical model does tend to be preoccupied with "what's wrong with you" biologically rather than "what happened to you" as a human being. It's a big blind spot, I think - we are such complex beings and there's such strong evidence linking trauma with mental illness, it seems, well..."crazy" for practitioners not to ask about it).
posted by embrangled at 2:51 AM on February 23, 2016 [8 favorites]

I've seen a few therapists and I don't think any of them have asked about my trauma history. I guess I wouldn't want to write it down in the waiting room of someone I haven't met yet .. to me it seems like something that I want to wait to talk about until I've had a few sessions and have grown to trust them. However all of my therapists have been helpful when I did bring it up.

So I don't think the fact that it's not on the form means it doesn't matter or they don't care. I do think you should ask about it and see what response you get.

Good luck.
posted by bunderful at 4:11 AM on February 23, 2016 [1 favorite]

Best answer: Other possible reasons: They might want to avoid retraumatizing you by bringing it up, they might want to let you be the one who initiates what will be discussed.
posted by Obscure Reference at 4:25 AM on February 23, 2016 [4 favorites]

I can't imagine asking for triggering information on the application form is a good start for a relationship anyway. It seems a really cold way of going about it.
posted by Jilder at 5:06 AM on February 23, 2016 [6 favorites]

I am from Canada, working in a large Mental Health Hospital which is affiliated with a city-wide Healthcare system, and they are currently working on integrating Trauma Informed Care into all areas of health care (i.e. to help refugees needing health care, or helping women in the Maternity ward who may have had a traumatic history with their partner, helping emergency responders, etc.)

If you trust your therapist, perhaps give them the nudge by asking what they know about trauma informed care, give them the opportunity to investigate. If they're thoughtful and sensitive to your needs, they should be willing to do the work to bring the best practices of trauma informed care into your therapeutic relationship.
posted by Dressed to Kill at 5:07 AM on February 23, 2016 [1 favorite]

Yeah, I think it's to avoid triggering. Often, it's a difficult subject to bring up gently. He's probably thinking that it's better for you to bring up yourself than to force you to, which could retraumatize you.
posted by kevinbelt at 5:19 AM on February 23, 2016 [1 favorite]

Best answer: Data point: my most recent "setting up with a new set of doctors" experience had them asking twice about past abuse (in the same section that asked if I've ever been to prison, just after all the pregnancy questions.) Their forms are super new, they seem to have come with their super new computer system. This was also the first time I remember being asked whether I've abused prescription medications in a separate line from illegal drugs.

I think that how old the forms are is the biggest factor, anyway. "Trauma informed care" is pretty new, and doctors seem to change forms only when they absolutely have to.
posted by SMPA at 5:45 AM on February 23, 2016

Part of the therapy process is for the patient to reveal traumas to the therapist. If a therapist came right out and asked about abuse, that could have the opposite effect, and make the patient clam-up. The therapist can lead them gently down that road, so that the patient comes to a place where they are comfortable/ready to reveal deep traumas like abuse.
posted by Thorzdad at 5:53 AM on February 23, 2016

Response by poster: I guess there were times it would have been appropriate for me to bring it up but I didn't realize. I do remember once saying to a therapist that there were some things in childhood I wanted to talk about, and he said it was better to concentrate on the present. (It's not an issue with my current therapist, since I went to see her specifically for this issue, but I wondered if it would be inappropriate to mention to the psychiatrist.)
posted by fair isle sock at 7:23 AM on February 23, 2016

Say you are going in because you have a chemical imbalance and a personality disorder, and the doctor does ask about past abuse. You could then spend so much time blaming everything on the past that the doctor could potentially miss the more urgent problems. By going in with an unbiased view, I would think that the doctor would have a more open field of vision for diagnosing you.
posted by myselfasme at 7:46 AM on February 23, 2016

On reflection, it may also be a function of a limited time frame for treatment. I don't know what your particular situation is and whether, say, you only get so many sessions paid for by insurance, but I do know that if I only had time for brief therapy with a client I would probably consider it irresponsible to open up past trauma unless it was directly relevant to the presenting problem. It's possible that was what your therapist meant when he said it was "better to concentrate on the present".

But other posters are right, trauma awareness is super important. When I worked in a suicide crisis centre I regularly saw people who had been bounced around for years in the medicalized mental health system being "treated" for one serious diagnosis after another, without anyone finding out or even inquiring about the horrific abuse they suffered in earlier life.
posted by stuck on an island at 8:28 AM on February 23, 2016

Every therapist I've ever seen has asked about my family history (which unfortunately includes a history of abuse in my situation). So if you've seen therapists and they haven't asked, I would say that's a bit unusual.

For psychiatrists though, it's not that strange. They tend to be more focused on mental illness with organic medical causes that they can treat with medications or other medical therapies. Which is okay for some conditions, but other mental illnesses really respond better to an approach that includes both medical intervention and therapy, like CBT. And if there is a history of trauma and abuse, that can majorly exacerbate the symptoms of most mental illnesses, and I think it'd be irresponsible for a psychiatrist to ignore that.
posted by katyggls at 10:39 AM on February 23, 2016

Best answer: Psychiatrist here, I would never dream of asking someone about abuse on a paper form. I do make a point of asking in my initial consultations however, so it is standard practice for me to ask. I was definitely trained in biospychosocial psychiatry but I'm in Canada, and I don't know what training is like in other countries.
posted by chemgirl at 10:16 PM on February 23, 2016

Response by poster: Update: this psychiatrist did bring up the subject in our first session. Maybe it never came up with other psychiatrists because they followed more of a biological model or just because I was reluctant to talk about it. Thanks for all the feedback.
posted by fair isle sock at 10:23 PM on February 24, 2016