How to ask adult mental health clients about sexual abuse

Content type

Short article

Published

September 2022

Project

Child Family Community Australia

Researchers

Jasmine B. MacDonald, Elly Quinlan

Content warning

If you require assistance or would like to talk to a trained professional about the issues described in this article, please call Lifeline on 13 11 14.

If you believe someone is in immediate danger call Police on 000.

Introduction

Individuals who have experienced sexual abuse are more likely to experience poor mental health outcomes. There is strong research evidence indicating that the experience of child sexual abuse is a unique risk factor for the development of mood disorders, anxiety disorders, posttraumatic stress disorder, substance abuse and sexual dysfunction (Noll, 2021). Research has also shown experiences of child sexual abuse to be associated with eating disorders, personality disorders and psychosis; however, other kinds of abuse may be contributing to this association (Noll, 2021). An Australian study indicated that adult survivors of sexual abuse are more likely than a matched control group to access mental health services and have higher prescription rates for psychopharmacological medication (Guha, Luebbers, Papalia, & Ogloff, 2019).

Mental health practitioners indicate that having knowledge of a client’s abuse history allows them to develop more effective clinical formulations, risk assessments and treatment plans (Young, Read, Barker-Collo, & Harrison, 2001). However, clients may only disclose their abuse with practitioners if they feel safe to do so (Chung, Fisher, Zufferey, & Thiara, 2018; Follette, La Bash, & Sewell, 2010; Read, McGregor, Coggan, & Thomas, 2006). Delayed disclosure and non-disclosure of sexual abuse are linked to greater levels of psychological distress and reduced access to appropriate support (Ahrens, Cabral, & Abeling, 2009; Bak et al., 2005).

This article outlines:

why adult survivors of sexual abuse may not disclose their abuse experiences to mental health practitioners
why practitioners might avoid asking about it
research findings from mental health practitioner samples on how to safely ask clients about sexual abuse histories.

Although not all mental health clients will have experienced sexual abuse or other kinds of trauma, asking all clients about their trauma histories is a way to manage cases in a trauma-informed way (Agar, Read, & Bush, 2002; Young et al., 2001). For this reason, the practitioner strategies covered later in this article refer to practice with adult mental health clients generally.

The evidence base described in this article is still emerging and tends to be descriptive in nature. It provides useful insights into client experiences as well as practitioner attitudes and practice strategies. Because of the current lack of evidence on the efficacy or effectiveness for client practices, the practice strategies reported here are those identified in research that has sampled mental health practitioners and asked them what they have found works best. These strategies have not been rigorously compared to alternative strategies with respect to client outcomes. In practice, this means it is useful to gauge the response the client is having to the enquiry, explain why you are asking about sexual abuse experiences, and prioritise the wellbeing of the client above the information-gathering process.

Why adult mental health clients may not disclose their sexual abuse histories

Survivors of sexual abuse may experience self-loathing, self-stigma, shame and mistrust of others (Deitz, Williams, Rife, & Cantrell, 2015; Dorahy, 2017; Gruenfeld, Willis, & Easton, 2017). They are less likely to disclose their sexual abuse history if they perceive the practitioner to be lacking empathy, dismissive or judgemental, or not believing their disclosure (Ahrens et al., 2009; Farber, Feldman, & Wright, 2014; Hennrick & Byrd, 2019; Page & Morrison, 2018; Starzynski & Ullman, 2014). When a practitioner responds with shock, disgust, anger or sadness, the client might feel vulnerable, overwhelmed and unlikely to disclose again in the future (Farber et al., 2014; Hennrick & Byrd, 2019; Nixon & Quinlan, 2021).

Why mental health practitioners might avoid asking clients about their sexual abuse histories

Mental health practitioners do not routinely ask clients about their sexual abuse histories. Research reviews of evidence from English-speaking Western countries indicate practitioner-reported enquiry rates as low as 18% (Hepworth & McGowan, 2013) and that client-reported enquiry by practitioners occurs in less than a quarter of cases (Read, Harper, Tucker, & Kennedy, 2018). Practitioners report not wanting to ask about client sexual abuse histories because of fear of damaging the therapeutic alliance, embarrassing the client, exacerbating the client’s condition and negative psychological impact on the practitioner from hearing the client’s story (Agar et al., 2002; Nixon & Quinlan, 2021; Young et al., 2001). Other reasons include personal discomfort for the practitioner, stigma of sexual abuse, low practitioner confidence and inexperience in responding to disclosures (Read et al., 2018).

When and how to ask clients about abuse histories

This table summarises research findings from mental health practitioner samples on when and how to safely ask clients about sexual abuse and other abuse histories.

When to ask	In an initial assessment. This means the questions can be asked in context and after building rapport (Agar et al., 2002; Young et al., 2001). Tip: Using an assessment form with an abuse section increases abuse disclosure rates from 17% to 60% across abuse types (Agar et al., 2002).
When not to ask	When the client is highly distressed, experiencing severe mental illness or strong current suicidality (Young et al., 2001). When you do not have time to respond appropriately to a disclosure (Young et al., 2001). When family members are present (Young et al., 2001). Tips: If the abuse history is not established during initial assessment, this can be documented in the case notes so that a follow-up enquiry about abuse can be made in a later session (Young et al., 2001). Any formulations and treatment plans should be considered provisional until a full abuse history is assessed (Young et al., 2001).
How to ask	Avoid broad questions like ‘Were you abused?’ as clients may not see themselves as having been ‘abused’ (Young et al., 2001). Start with general questions about their childhood experiences like: ‘What was the worst thing that ever happened to you as a child?’ (Young et al., 2001) When working with any client, if the general approach does not result in disclosure, ask some specific questions that are detailed and behaviourally descriptive about physical, emotional and sexual abuse and neglect (Nixon & Quinlan, 2021; Young et al., 2001), like: ‘Did a family member or other adult ever treat you in a way that left a bruise or cut or made you bleed?’ For examples of other general and specific questions, see the Victorian Department of Health suggestions. The suggestions provided by the Victorian Department of Health are consistent with the broader guidelines summarised in this table (Young et al., 2001). Ask about abuse experiences that might have occurred since childhood (Young et al., 2001). Normalise the experience and the therapeutic reason to ask about it (Nixon & Quinlan, 2021). Use empathetic and respectful responses that demonstrate the credibility of any disclosure (Ahrens et al., 2009; Faber et al, 2014; Hennrick & Byrd, 2019; Page & Morrison, 2018; Starzynski & Ullman, 2014). Avoid responding to any disclosure in a way that conveys shock, disgust, anger, sadness (Faber et al, 2014; Hennrick & Byrd, 2019; Nixon & Quinlan, 2021) or unintentional physical and verbal cues of discomfort (e.g. looking away or moving away in your chair or changing the line of questions to something else) (Follette et al., 2010).

When to ask

In an initial assessment. This means the questions can be asked in context and after building rapport (Agar et al., 2002; Young et al., 2001).

Tip: Using an assessment form with an abuse section increases abuse disclosure rates from 17% to 60% across abuse types (Agar et al., 2002).

When not to ask

When the client is highly distressed, experiencing severe mental illness or strong current suicidality (Young et al., 2001).
When you do not have time to respond appropriately to a disclosure (Young et al., 2001).
When family members are present (Young et al., 2001).

Tips: If the abuse history is not established during initial assessment, this can be documented in the case notes so that a follow-up enquiry about abuse can be made in a later session (Young et al., 2001). Any formulations and treatment plans should be considered provisional until a full abuse history is assessed (Young et al., 2001).

How to ask

Avoid broad questions like ‘Were you abused?’ as clients may not see themselves as having been ‘abused’ (Young et al., 2001).
Start with general questions about their childhood experiences like: ‘What was the worst thing that ever happened to you as a child?’ (Young et al., 2001)
When working with any client, if the general approach does not result in disclosure, ask some specific questions that are detailed and behaviourally descriptive about physical, emotional and sexual abuse and neglect (Nixon & Quinlan, 2021; Young et al., 2001), like: ‘Did a family member or other adult ever treat you in a way that left a bruise or cut or made you bleed?’
- For examples of other general and specific questions, see the Victorian Department of Health suggestions. The suggestions provided by the Victorian Department of Health are consistent with the broader guidelines summarised in this table (Young et al., 2001).
Ask about abuse experiences that might have occurred since childhood (Young et al., 2001).
Normalise the experience and the therapeutic reason to ask about it (Nixon & Quinlan, 2021).
Use empathetic and respectful responses that demonstrate the credibility of any disclosure (Ahrens et al., 2009; Faber et al, 2014; Hennrick & Byrd, 2019; Page & Morrison, 2018; Starzynski & Ullman, 2014).
Avoid responding to any disclosure in a way that conveys shock, disgust, anger, sadness (Faber et al, 2014; Hennrick & Byrd, 2019; Nixon & Quinlan, 2021) or unintentional physical and verbal cues of discomfort (e.g. looking away or moving away in your chair or changing the line of questions to something else) (Follette et al., 2010).

Conclusion

Mental health practitioners are able to develop more effective clinical formulations, risk assessments and treatment plans when they have knowledge about the client’s sexual abuse history (Young et al., 2001). However, adult mental health clients may choose not to disclose their experiences of abuse without being prompted. Reasons for this include self-loathing, self-stigma, shame, mistrust of others and previous experiences with practitioners who were perceived to lack empathy, be dismissive or were shocked by previous disclosures.

Mental health practitioners can facilitate disclosures of abuse from the clients they support by:

incorporating routine enquiry about sexual abuse into the initial assessment with a client unless contra-indicated (see ‘When not to ask’ in the table above)
providing a safe space for disclosure
keeping their personal responses in check when disclosures occur.

References

Agar, K., Read, J., & Bush, J.-M. (2002). Identification of abuse histories in a community mental health centre: The need for policies and training. Journal of Mental Health, 11(5), 533–543. doi:10.1080/09638230020023886

Ahrens, C. E., Cabral, G., & Abeling, S. (2009). Healing or hurtful: Sexual assault survivors' interpretations of social reactions from support providers. Psychology of Women Quarterly, 33(1), 81–94. doi:10.1111/j.1471-6402.2008.01476.x

Bak, M., Krabbendam, L., Janssen, I., de Graaf, R., Vollebergh, W., & van Os, J. (2005). Early trauma may increase the risk for psychotic experiences by impacting on emotional response and perception of control. Acta Psychiatrica Scandinavica, 112(5), 360–366. doi.org/10.1111/j.1600-0447.2005.00646.x

Chung, D., Fisher, C., Zufferey, C., & Thiara, R. (2018). Preventing sexual violence against young women from African backgrounds. Australian Institute of Criminology (Report No. 540). doi:10.3316/agispt.20182262

Deitz, M. F., Williams, S. L., Rife, S. C., & Cantrell, P. (2015). Examining cultural, social, and self-related aspects of stigma in relation to sexual assault and trauma symptoms. Violence Against Women, 21(5), 598–615. doi:10.1177/1077801215573330

Dorahy, M. J. (2017). Shame as a compromise for humiliation and rage in the internal representation of abuse by loved ones: Processes, motivations, and the role of dissociation. Journal of Trauma & Dissociation, 18(3), 383–396. doi:10.1080/15299732.2017.1295422

Farber, B. A., Feldman, S., & Wright, A. J. (2014). Client disclosure and therapist response in psychotherapy with women with a history of childhood sexual abuse. Psychotherapy Research, 24(3), 316–326. doi:10.1080/10503307.2013.817695

Follette, V. M., La Bash, H. A. J., & Sewell, M. T. (2010). Adult disclosure of a history of childhood sexual abuse: Implications for behavioral psychotherapy. Journal of Trauma & Dissociation, 11(2), 228–243. doi:10.1080/15299730903502953

Gruenfeld, E., Willis, D. G., & Easton, S. D. (2017). ‘A very steep climb’: Therapists’ perspectives on barriers to disclosure of child sexual abuse experiences for men. Journal of Child Sexual Abuse, 26(6), 731–751. doi:10.1080/10538712.2017.1332704

Guha, A., Luebbers, S., Papalia, N., & Ogloff, J. R. P. (2019). A follow-up study of mental health service utilisation in a cohort of 2433 sexually abused Australian children utilising five years of medical data. Child Abuse & Neglect, 90, 174–184. doi:10.1016/j.chiabu.2019.01.015

Hennrick, H. C., & Byrd, M. (2019). Survivor-therapists and sexual-assailant-clients: A unified approach to sexual communication skills building and assault prevention. Journal of Psychotherapy Integration, 29(2), 138–150.

Hepworth, I., & McGowan, L. (2013). Do mental health professionals enquire about childhood sexual abuse during routine mental health assessment in acute mental health settings? A substantive literature review. Journal of Psychiatric and Mental Health Nursing, 20(6), 473–483. doi.org/10.1111/j.1365-2850.2012.01939.x

Nixon, B., & Quinlan, E. (2021). Asking the hard questions: Psychologists’ discomfort with inquiring about sexual abuse histories. Violence Against Women, 28(5), 1358–1376. doi:10.1177/10778012211014558

Noll, J. G. (2021). Child sexual abuse as a unique risk factor for the development of psychopathology: The compounded convergence of mechanisms. Annual Review of Clinical Psychology, 17(1), 439–464. doi:10.1146/annurev-clinpsy-081219-112621

Page, A., & Morrison, N. M. V. (2018). The effects of gender, personal trauma history and memory continuity on the believability of child sexual abuse disclosure among psychologists. Child Abuse & Neglect, 80, 1–8. doi.org/10.1016/j.chiabu.2018.03.014

Read, J., Harper, D., Tucker, I., & Kennedy, A. (2018). Do adult mental health services identify child abuse and neglect? A systematic review. International Journal of Mental Health Nursing, 27(1), 7–19. doi:10.1111/inm.12369

Read, J., McGregor, K., Coggan, C., & Thomas, D. R. (2006). Mental health services and sexual abuse: The need for staff training. Journal of Trauma & Dissociation, 7(1), 33–50. doi:10.1300/J229v07n01_04

Starzynski, L. L., & Ullman, S. E. (2014). Correlates of perceived helpfulness of mental health professionals following disclosure of sexual assault. Violence Against Women, 20(1), 74–94. doi:10.1177/1077801213520575

Young, M., Read, J., Barker-Collo, S., & Harrison, R. (2001). Evaluating and overcoming barriers to taking abuse histories. Professional Psychology: Research and Practice, 32(4), 407–414. doi:10.1037/0735-7028.32.4.407

Featured image

Topics

Research findings

Practice resources

About us

Media centre

How to ask adult mental health clients about sexual abuse

Content warning

Introduction

Why adult mental health clients may not disclose their sexual abuse histories

Why mental health practitioners might avoid asking clients about their sexual abuse histories

When and how to ask clients about abuse histories

Conclusion

Further reading and related resources

References

How to ask adult mental health clients about sexual abuse

Content warning

Introduction

Why adult mental health clients may not disclose their sexual abuse histories

Why mental health practitioners might avoid asking clients about their sexual abuse histories

When and how to ask clients about abuse histories

Conclusion

Further reading and related resources

References

Related topics