Ritualistic Abuse Survivors Difficulties Obtaining Services – Neil Brick

Ritualistic Abuse Survivors Difficulties Obtaining Services

Neil Brick

Neil Brick is a survivor of ritualistic abuse. His work continues to educate the public about child abuse, trauma, and ritualistic abuse crimes. His child abuse and ritualistic abuse newsletter S.M.A.R.T. and website have been published for over 29 years.  https://ritualabuse.us http://neilbrick.com

Ritualistic Abuse Survivors Difficulties Obtaining Services

 Ritualistic abuse survivors have struggled to obtain adequate mental health and social support services for over twenty years. This problem has been exacerbated by a lack of trained providers and adequate social services to deal with the complex problems ritualistic abuse survivors present. Most clinicians do not receive proper training due to severe trauma topics and their symptomatology not being adequately covered in their master level training programs or in post continuing education training. Very few organizations are available to educate clinicians and survivors about the research in the field. Insurance companies often do not adequately cover services for long term treatment. Social services employees are not adequately trained to work with severe trauma survivors.

Ritualistic Abuse Survivors Difficulties Obtaining Services

 There is a paucity of training regarding trauma informed services and ways to work with clients suffering from dissociative disorders. Application guidelines often make it very difficult for ritualistic abuse survivors to receive in the timelines given. Survivors may have difficulties getting to offices, getting on the Internet or filling out paperwork. This presentation will include the presenter’s own struggles receiving adequate services over the last thirty years. Issues to be discussed will include the symptomatology of dissociative disorders, attachment disorders, mood and anxiety disorders, economic problems, and social barriers. Solutions to decrease and eliminate these difficulties will be discussed. These will include public advocacy, public education, survivor training, and the building of a research base to help survivors and their helpers move forward to prevent these difficulties in the future.

Presentation Objectives

Discuss the four key concepts regarding the lack of education for those working with ritualistic abuse survivors.

Describe reasons why ritualistic abuse survivors have difficulties obtaining services.

Describe ways ritualistic abuse survivors and their helpers can change the present system to increase services for these survivors.

Trigger Warning: This presentation contains information (written, spoken, or visual) that may be triggering or (re)traumatizing to attendees.

 Ritualistic abuse survivors have struggled to obtain adequate mental health and social support services for over twenty years.

Research in health and welfare settings has found that adults with histories of organised and/or ritualistic abuse are presenting in a range of health and welfare contexts (Cooper, 2004; Schmuttermaier & Veno, 1999) although their complex mental health needs often go unmet (Courtney & Williams, 1995; Freer & Seymour, 2003; NSW Health, 1997). (Salter, 2012)

Ritualistic abuse survivors have struggled to obtain adequate mental health and social support services for over twenty years.

Describe reasons why ritualistic abuse survivors have difficulties obtaining services

 Mental health care needs of people who have been subject to organised abuse

 The research literature links sexual abuse or coercion in childhood to a range of mental, physical and sexual health problems in adulthood (Maniglio, 2009) although not all sexually abused children experience such long-term effects (Rind et al., 1998). The impact of sexual abuse upon victims is related to such factors as the child’s familial and community environment and relationship between perpetrator and victim (Briere & Elliott, 1993) and particular characteristics of abuse. The factors associated with long-term harm amongst sexual abuse victims, such as multiple perpetrators, more frequent incidents of abuse, a longer period of abuse, familial perpetrators, the use of  force/threats/drugs and penetrative abuse (Briere & Runtz, 1988; Casey & Nurius, 2005; Dube et al., 2005) are common features of organised abuse (Gallagher et al., 1996) (Salter, 2012)

 Ritualistic abuse survivors have struggled to obtain adequate mental health and social support services for over twenty years.

In particular, these characteristics are associated with complex forms of post-traumatic stress disorder and dissociative spectrum disorders. In cases of organised abuse, clinicians have suggested that traumatic and Dissociative psychopathology may be deliberately induced by sexually abusive groups to inhibit victim disclosure and reduce the likelihood of detection (Epstein et al., 2011; Miller, 2012; Sachs & Galton, 2008), resulting in what Chu (2011, p. 263) has described as “massive devastation of the self”. Shengold (1979) employed the term “soul murder” to describe the subjective experience of “living-deadness” produced by early, chronic and repetitive abuse. There is ample evidence that people with histories of organised abuse constitute a population of mental health patients with acute and complex needs (Ross, 1995; Noblitt & Perskin, 2000; Sachs & Galton, 2008). This literature overlaps with the body of clinical literature and research on dissociative spectrum disorders, particularly DID, that has developed since the 1980s (Fraser, 1990; Kluft et al., 1984; Mollon, 1996). Middleton (2005, p. 41) (Salter, 2012)

Ritualistic abuse survivors have struggled to obtain adequate mental health and social support services for over twenty years.

Describe reasons why ritualistic abuse survivors have difficulties obtaining services

There are many underserved communities that have been historically marginalized, oppressed, and exploited. Sexual abuse survivors are one such group whose oppression is becoming recognized due to advocacy and social movements such as the “Me Too” Movement, although there has also been a backlash (Noblitt & Noblitt, 2021).  Unfortunately, even when healthcare providers are at their best in terms of competence and ethical practice, there continue to be daunting and sometimes overwhelming systemic obstacles for extreme abuse survivors. (Noblitt – Extreme, 2024)

Organized and ritual child sexual abuse (ORA) is often rooted in the child’s own family. Empirical evidence on possible associations between ORA and trauma-related symptoms in those who report this kind of extreme and prolonged violence is rare. The aim of our study was to explore socio-demographic and clinical characteristics of the individuals reporting ORA experiences, and to investigate protective as well as promotive factors in the link between ORA and trauma-related symptom severity. Within the framework of a project of the Independent Inquiry into Child Sexual Abuse in Germany, we recruited 165 adults who identified themselves as ORA victims via abuse- and trauma-specific networks and mailing lists, and they completed an anonymous online survey. We used variance analyses to examine correlations between several variables in the ORA context and PTSD symptoms (PCL-5) as well as somatoform dissociation (SDQ-5). Results revealed a high psychic strain combined with an adverse health care situation in individuals who report experiences with ORA. Ideological strategies used by perpetrators as well as Dissociative Identity Disorders experienced by those affected are associated with more severe symptoms (η2p = 0.11; η2p = 0.15), while an exit out of the ORA structures is associated with milder symptoms (η2p = 0.11). Efforts are needed to improve health care services for individuals who experience severe and complex psychiatric disorders due to ORA in their childhood.  (Schroder, 2018)

This problem has been exacerbated by a lack of trained providers and adequate social services to deal with the complex problems ritualistic abuse survivors present.

Discuss the four key concepts regarding the lack of education for those working with ritualistic abuse survivors.

Deficits in trauma training

Deficits in training regarding dissociative disorders

Deficits in training regarding organized/ritual abuse

Deficits in training regarding toxic stress

This problem has been exacerbated by a lack of trained providers and adequate social services to deal with the complex problems ritualistic abuse survivors present.

 Teaching Trauma and Dissociation in Higher Education – Clinicians can contribute to the wellbeing of extreme abuse survivors directly by providing competent professional services. We can also assist by training graduate students who will become future clinicians. Folz and colleagues (2023) found deficits in trauma-informed training in their sample of 193 APA-accredited clinical psychology programs. Only 5% required a course relevant to trauma-informed care, resulting in only 8% of graduates receiving such formal training. (Noblitt – Teaching – 2024)

Many clinicians are not well informed about the psychological effects of trauma. Many clinicians are unfamiliar with dissociation. Many universities do not provide sufficient training on this topic. Foltz, R., Kaeley, A., Kupchan, J., Mills, A., Murray, K., Pope, A., Rahman, H., & Rubright, C. (2023). Trauma-informed care? Identifying training deficits in accredited doctoral programs. Psychological Trauma : Theory, Research, Practice and Policy, 10.1037/tra0001461.  (Noblitt – Teaching, 2024)

This problem has been exacerbated by a lack of trained providers and adequate social services to deal with the complex problems ritualistic abuse survivors present.

My personal experience (Noblitt): No dissociation and trauma training until in private practice seeing clients with histories of trauma and dissociation. I joined a “study group” and attended continuing education programs. Lack of support by some institutions and threats from the backlash. (Noblitt – Teaching, 2024)

In the patient care setting, particularly in trauma or other disciplines that care for individuals from oppressed populations, it is common to encounter patients who carry histories of individual, interpersonal, and/or collective trauma. These experiences impact both patient health and the ways in which they engage with their healthcare. Given that there is neither time nor precedent to understand ACE and trauma history before trauma evaluation, it is imperative that care providers recognize the impact of the unspoken traumas that are brought to the clinical encounter.  Most clinicians do not receive proper training due to severe trauma topics and their symptomatology not being adequately covered in their master level training programs or in post continuing education training. (Grossman et al, 2021)

This problem has been exacerbated by a lack of trained providers and adequate social services to deal with the complex problems ritualistic abuse survivors present.

Healthcare services themselves can unintentionally traumatize or re-traumatize people….Using trauma-informed care in a universal precaution method can address these concerns. One practical solution is to ask patients broad trauma inquiry such as “Have you had any life experiences that you feel have impacted your health and well-being?”8 Questions like these allow surgical teams and providers to understand not only acute traumas present, the potential causal interpersonal aspects of this trauma, but also the effects of collective/structural trauma.9 The Substance Abuse and Mental Health Administration (SAMHSA) summarizes this type of trauma-informed proactive approach as the “4 R’s” wherein providers seek to Realize how trauma affects the individuals and communities they serve in their practice, Recognize the symptoms of trauma in their patients, Respond to patients in a trauma-informed way, and Resist Re-traumatization of patients.10 This stance allows care providers to move beyond the conception of “what’s wrong with you” when assessing patients, to the broader question “what happened to you and how has what happened affected you?” This advances providers’ ability to pro-actively address trauma histories by asking patients what would be helpful before healthcare encounters, and to collaborate with healthcare teams to offer referrals or resources as needed.11 This universal trauma approach allows providers to address “hidden” traumas (undisclosed or unaccounted), as well as those that are rooted in collective and structural trauma. (Grossman et al, 2021)

Toxic stress, historical trauma, and epigenetics (The importance of receiving proper care.)

Toxic stress can come from trauma at all levels, and stress can come from all levels of trauma. For example, a person can experience relative resiliency in their personal lives, while still experiencing intergenerational trauma due to historical occurrences such as slavery or genocide. The stress response is understood as both psychological and physiologic. When the body’s fight or flight, or adrenergic, response is activated, stress hormones like epinephrine and cortisol are released. Over time, when the stressful stimulus is removed, individuals return to homeostasis and the stress response subsides. However, for individuals who live in situations of chronic stress, it can become difficult to return to homeostasis. This experience of living with chronic stress and constant, low level activation of the adrenergic system creates changes in the brain, learning, and responses, and creates altered reactions to stress in the future. Known as toxic stress, this response has been linked to poor health outcomes, increased incidence of psychiatric and substance abuse disorders, and decreased immune responses. (Grossman et al, 2021)

Social services employees are not adequately trained to work with severe trauma survivors. There is a paucity of training regarding trauma informed services and ways to work with clients suffering from dissociative disorders.

“Trauma-informed care has become a pillar of competent psychological services. A foundation in understanding trauma and its treatment should be viewed as essential for clinical psychologists entering the field, as working with individuals that have experienced trauma is inevitable” (p. 1188).  Although this article is about psychologists, can we agree that all MH professionals should have these skills and competencies?  (Noblitt – Teaching, 2024)

Another surprising thing about the literature of trauma-informed care is that it is difficult to find much information or commentary about extreme abuse. One exception is Dr. Cortny Stark’s informative case study of “Sarah” where the author described the details of a sophisticated trauma-informed approach. The author noted that “Clients who report complex childhood trauma, particularly ritual and cultic abuse, often present information in session that seems chaotic and emotionally charged. Providing clients with a rationale for both understanding their problem and the necessary treatment is essential to achieving positive outcomes” (Stark, 2019, p. 51). My question is how can clinicians be truly trauma-informed if they deny, neglect, or ignore extreme abuse? (Noblitt – Trauma, 2024)

Building a trauma-informed organization

Understanding trauma-informed principles and the effects of ACEs on the provider–patient relationship is not enough; it is critical to implement trauma-informed practices throughout the institution. Physicians are in a position within hospitals, educational institutions, and medical systems to build an entire system that is trauma-informed.19 This can be accomplished through formal teaching and training, mentoring, and through the establishment of trauma-informed institutional structures. Nursing literature has informed the field on trauma-informed care for decades.20–22 A synthesis of the nursing literature on TIC revealed the following themes: trauma screening and patient disclosure, provider–patient relationships, minimizing distress and maximizing autonomy, multidisciplinary collaboration and referrals, and advancement of TIC in diverse settings. (Grossman et al, 2021)

Trauma-informed care

For clients. Trauma-informed organizations strive to create physically and emotionally safe spaces and prioritize practices that honor victim voice and choice.[17] Implementing trauma-informed care requires changes to the practices and policies at all levels of the organization to ultimately prevent re-traumatization of clients seeking services. In being trauma-informed in their approaches, many systems presume every person who walks through their doors has been exposed to abuse, violence, neglect, or other traumatic event(s).[18] When implemented properly, trauma-informed care fosters resilience in victims. Resilience is the capacity to cope with stress, overcome adversity, and thrive in life, despite one’s victimization experience or other life challenges. Building resilience in victims is an ongoing process that requires continual time and effort from both the victim and service provider. (Kolis, 2018)

Implementing trauma-informed care

 Implementing trauma-informed care can be complex and requires changes within the structures and environment of the organization.[35] These structures may include the mission, staffing, policies, protocols, procedures, culture, and the physical environment of the organization. SAMHSA offers these domains that should be considered during implementation of trauma-informed care:

   Governance and Leadership: Support and fully invest in implementation and sustainability.

    Policy: Establish and reinforce trauma-informed care as the organizational mission.

    Physical Environment: Foster a sense of safety and collaboration.

    Victim Engagement and Involvement: Actively involve victims and their voices actively in all aspects of decision-making within the organization.

    Cross Sector Collaboration: Promote a shared understanding of trauma-informed aspects and principles across all sectors. (Kolis, 2018)

Implementing trauma-informed care (cont.)         

Screening, Assessment, Treatment Services: Complete trauma assessment and screening to guide the care plan. A referral system must be in place for treatment services that the organization is unable to deliver.

    Training and Workforce Development: Conduct ongoing training and development of staff.

    Progress Monitoring and Quality Assurance: Engage in ongoing assessment, tracking, and monitoring of trauma-informed practices for quality assurance.

    Financing: Build financial structures to support and plan for sustainability.

    Evaluation: Create evaluation designs that reflect an understanding of trauma and utilize appropriate trauma-oriented research instruments (Kolis, 2018)

Dissociative patients are an underserved group.

According to Dr. Bethany Brand dissociative “patients are an underserved group who are sometimes distressed and even mistreated rather than helped by clinicians” (Brand, 2024, p. 69). What factors may be at the root of the failure of some providers to appropriately recognize and treat dissociative patients? I suggest that financial interests play a significant role in the maltreatment of survivors by clinicians. Most clinicians do not receive proper training due to severe trauma topics and their symptomatology not being adequately covered in their master level training programs or in post continuing education training.  Very few organizations are available to educate clinicians and survivors about the research in the field.  (Noblitt – Extreme, 2024)

 It may be possible that health care professionals without experience in treating trauma more frequently attribute dissociative and hallucination symptoms to classic psychiatric diagnoses like schizophrenia or BPD than to controversial and/or neglected disorders like DID [73]. A possible high rate of inaccurate psychiatric diagnoses by health care professionals may also result in an application of inadequate psychotherapeutic methods, a lack of effective psychotherapeutic methods, or inadequate psychopharmacological treatment, and may lead to a poor health care situation despite the previously-proposed good integration into health care structures. The possible inaccuracy of the participants’ appraisal regarding incorrect diagnoses is associated with a limited validity, and suggests a more precise elaboration in future research, for example, by examining this topic in a sample of psychotherapists, who are experienced in diagnosing and treating individuals with ORA experiences.  (Schroder, 2018)

Insurance companies often do not adequately cover services for long term treatment.

 

Describe reasons why ritualistic abuse survivors have difficulties obtainIt is estimated that about half of the US population is diagnosed with a mental illness at some point in their life; in 2015, ∼20% of all adults had a mental illness and 4% had serious mental illness and over one-fifth of children had a serious mental illness.1 Mental illnesses are identified as the third most common cause of hospitalizations among 18–44 years old adults 2 and lead to a shorter life expectancy. 3 In the United States, mental illness accounts for the second largest disease burden, and severe mental health disorders account for about a quarter of hospital admissions and disability payments. 4 About half of these chronic illnesses begin by age 14 and 75% begin by age 24. 1 If detected early in childhood or adolescence, many mental health conditions can be managed effectively or occasionally prevented entirely in adulthood, which will substantially reduce the economic and psychological burden.

 Despite evidence that early detection and treatment can ease the impact on outcomes and reduce the prevalence of mental illnesses, ∼70% of children and adolescents do not receive needed mental health treatment services.4,5 Inadequate insurance coverage for mental illness is reported as one of the primary reasons for such insufficient access.4,6,7 (Heboyan, 2021)

Insurance companies often do not adequately cover services for long term treatment.

 

Describe reasons why ritualistic abuse survivors have difficulties obtaining services

We found that the number of mental health treatment visits declined as cumulative exposure to mental health insurance legislation increased; a 10 unit (or 10.3%) increase in the law exposure strength resulted in a 4% decline in the number of mental health visits. We also found that state mental health insurance laws are associated with reducing mental health treatments and disparities within at-risk subgroups. Prolonged exposure to comprehensive mental health laws across a person’s childhood and adolescence may reduce the demand for mental health visitations in adulthood, hence, reducing the burden on the payors and consumers. Further, as the exposure to the mental health law strengthened, the gap between at-risk subgroups was narrowed or eliminated at the highest policy exposure levels. (Heboyan, 2021)

Insurance companies often do not adequately cover services for long term treatment.

Research has established a link between ACEs and problems in adulthood, including mental health problems, substance misuse, and underemployment.41 Our study suggests that stronger mental health insurance laws are associated with a significantly lower number of visits as an adult reported by those with 3+ ACEs in childhood as compared with those with 3+ ACES who were exposed to weak mental health laws. Taken in the context of the mental health care needs of those experiencing ACEs, our study implies that mental health insurance laws are likely important for improving adult outcomes for those experiencing a greater need as a child. While additional research is needed to further establish these linkages and pathways, our results suggest that strong mental health insurance laws are an important moderator. These findings are very promising and may guide policymakers and mental health advocates on improving access and utilization of mental health services in the future. (Heboyan, 2021)

Survivor dependency on Medicaid insurance or other public assistance

 Based on my own clinical practice, many, if not most survivors are at a financial disadvantage due to their histories that likely interrupted their education, job training, earnings capacity, and social development leaving them without the money for private insurance and leaving them dependent on Medicaid insurance or other public assistance. Medicaid is notorious for its poor reimbursement policies and is typically eschewed unless it is a secondary payer to Medicare or some other private insurance provider. Fewer and fewer clinicians and facilities are willing to see Medicaid patients and when they do, are willing to do so for only brief therapy or diagnostics. And in order to obtain the highest reimbursement from Medicaid, the clinicians may attribute diagnoses such as schizophrenia, schizoaffective disorder, or others to their dissociative patients that rely primarily on medication rather than psychotherapy, according to insurers. This leaves the psychiatrist or psychotherapist with only a requirement for a quarterly 15-minute medication check to determine whether the prescribed medications are adequate or require adjustment. The problem is that for patients who do not actually experience schizophrenia or like disorders, the medication is unlikely to be helpful and this may result in unnecessary changes to medications and dosages that may be equally ineffective but that satisfy Medicaid’s requirements for reimbursement. (Noblitt – Extreme, 2024)

Application guidelines often make it very difficult for ritualistic abuse survivors to receive in the timelines given.

Describe reasons why ritualistic abuse survivors have difficulties obtaining services
Describe ways ritualistic abuse survivors and their helpers can change the present system to increase services for these survivors

As healthcare providers we need to recognize that extreme abuse survivors are an underserved community, and advocate for their recognition and their opportunity to access health services, employment, and disability-related supports. But the solution to this serious dilemma may be political rather than therapeutic. Where once the processing time for applying for Social Security disability programs including Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) was 30-60 days, the processing time is now 200-300 days nationally. In California, the average processing time is 245 days. And the initial application is only the first step. It is safe to assume that the initial application will be denied, since that is the fate of the majority of applications unless it can be demonstrated that the individual has a potentially fatal condition such as stage IV cancers, end stage renal disease, or being on the UNOS organ transplant list. Denied initial applications require the claimant to file a reconsideration appeal that will also likely result in the same processing time as the initial application. It is only after receiving a denial for the reconsideration appeal that the claimant can request a hearing before an administrative law judge, the stage at which most claimants are awarded benefits. (Noblitt- Extreme, 2024)

 

Application guidelines often make it very difficult for ritualistic abuse survivors to receive in the timelines given.

Describe reasons why ritualistic abuse survivors have difficulties obtaining services
Describe ways ritualistic abuse survivors and their helpers can change the present system to increase services for these survivors

Likewise, the reimbursement schedule for Medicaid, Medicare, and private insurers must be more realistically restructured in accordance with the cost of living. Increasing the numbers of public mental healthcare facilities that feature adequate numbers of appropriately trained mental health providers is essential. And providing for adequate housing, access to food, social services, medical treatment, and safety for survivors is an absolute. This will require providers and survivors to petition local, state and federal elected officials to recognize dissociative patients as an underserved population and develop services that meet these people’s needs. (Noblitt- Extreme, 2024)

Survivors may have difficulties getting to offices, getting on the Internet or filling out paperwork.

Studies from the early 2000s reported that parity laws increased mental health treatment utilization by adults with mild symptoms and low-income individuals. However, only a small effect was reported among children.9,12–14 Results from more recent studies were not conclusive. McGinty et al15 found increased utilization of substance use disorder treatment, while others reported no changes in these rates.16–20 Li and Ma4 identified that state mental health insurance laws resulted in modest increases in mental health care utilization among children from middle-income families. Sipe et al21 found that although mental health legislation broadly appeared to improve mental health outcomes for US populations, generally, few studies examine high-risk populations who experience access problems (p. 763).21 (Heboyan, 2021)

Survivors may have difficulties getting to offices, getting on the Internet or filling out paperwork.

Alternatively, some dissociative patients may seek treatment from state, county, or city public mental health facilities, also chronically understaffed and underfunded. While the mental healthcare professionals may be caring and understanding of the patient’s true diagnosis and appropriate treatment, they often do not have the time or latitude to provide needed care due to the guidelines imposed by the facilities and huge caseloads with which the providers are tasked. Furthermore, in addition to the scarcity of affordable mental healthcare, there are competing issues for the patient around transportation and meeting basic needs for housing, food, and safety that interfere with their mobility and ability to adhere to a regular therapy schedule where such services exist.  (Noblitt – Extreme, 2024)

 This presentation will include the presenter’s own struggles receiving adequate services over the last thirty years.

Problems getting insurance

Problems finding trained therapists

Cost of therapy

Trust issues

Attachment issues

Work issues/scheduling

Issues to be discussed will include the symptomatology of dissociative disorders, attachment disorders, mood and anxiety disorders, economic problems, and social barriers.

Lack of training regarding these diagnoses and misdiagnoses.

Abuse and dissociation: a cycle

Dissociation is created through severe abuse

The existence of dissociation then allows further abuse to be committed, as the horror and hurt are disowned and future danger ignored.

The trauma caused by continual exposure to abuse (as a victim, witness, perpetrator or a combination of them) necessitates further use of dissociation.  The more this cycle is repeated, the more entrenched it becomes. This is a dissociative disorder.  (Sachs, 2024)

The Attachment RelationshipAttachment is an instinct – Activated by fear and distress – Alleviated by the attachment figure’s attention

The attachment relationship:

High & frequent distress

Dependency, Attentive parenting

Independence

Concrete Infanticidal Attachment:

Essential Attributes

A childhood (or longer) of involvement in violent, sadistic and life-threatening crime as a victim, witness, perpetrator or any combination of them.

These crimes are carried out within a group to which one belongs, willingly or otherwise, such as a religious sect, a family, a military offshoot, a paedophile ring etc.

This group serves as the person’s attachment figure (note the attachment plurality, mirrored in the structure of DID).

Within the group, the relevant crimes are deemed moral or even virtuous (if not legal).

The deepest moments of relatedness to the attachment figure (the group) are reached during the performance of these crimes.

The severity of the DID is related to the perceived cohesiveness, size and power of the group as a whole, as well as to the intensity of the violence.  (Sachs, 2024)

Trauma and Psychological Disorders

Trauma factors into a variety of psychological disorders and conditions that otherwise one might not expect. For example, in a large sample of people diagnosed with bipolar disorder (577 participants) Samantha Russell and her colleagues found that “12 % (n =75) reported one trauma, 72 % (n =417) reported multiple traumas, and 14 % (n =85) had an identified comorbid diagnosis of PTSD” (2024, p. 278). The authors concluded that, “An important practical implication of this study is the need for trauma informed care in health care services, not only to improve the identification of trauma and PTSD in patients, but to improve health outcomes of the patients and their families” (2024, p. 280). Common problems in living such as insomnia are being seen as potentially related to trauma experiences (Fellman et al. 2021). (Noblitt – Trauma, 2024)

The Impact of Trauma on Individual Health

Traumatic experiences can leave victims with a multitude of symptoms, including, but not limited to, a loss of hope, excessive fear, strained relationships with family, friends, employers, and others, depression, anxiety, sleep disturbances, and feelings of excessive guilt or self-blame.[3] Collectively, these symptoms can be referred to as traumatic stress reactions and may be indicators of PTSD. Traumatic stress reactions often impact an individual’s behavioral and physical health, and affect daily functioning.[4] (Kolis, 2018)

 

Complex clinical pictures of severe trauma-related and dissociative disorders

 Clients who identify as victims of ORA present themselves in a range of health and welfare contexts, and report complex clinical pictures of severe trauma-related and dissociative disorders [19]. Health care professionals, who support clients reporting ORA experiences, observe clinical syndromes that go beyond clinical criteria of post-traumatic stress disorders (PTSD), which are primarily interpersonal disturbances, negative self-concepts, and affect dysregulation [20,21]. Individuals with complex PTSD tend to show higher dissociation scores than those with PTSD, and dissociation scores are further related to fear of relationships and withdrawal from shame-evoking situations [22]. Dissociative disorders, characterized by disruptions and/or discontinuities during the normal processes of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior [23], have been frequently attributed to severe trauma experienced during early childhood [24]. Dissociative experiences, ranging from mild detachment from current surroundings to severe detachment and identity fragmentation, allow for psychological protection through detachment when fight/flight responses are impossible [25]. Evidence suggests a link between accumulated exposure to various types of trauma (e.g., sexual, physical, and emotional abuse) and severity of dissociation symptoms [26]. (Schroder, 2018)

Complex clinical pictures of severe trauma-related and dissociative disorders (cont.)

Females of a German sample with either dissociative identity disorder (DID), which is the most severe syndrome of this spectrum, or a dissociative disorder not otherwise specified (DDNOS), which comprises clinical pictures that do not meet full but similar criteria, suffered from five comorbid diagnoses on average, whereas most of them had a clinically-diagnosed PTSD comorbidity [27,28,29]. Somatoform dissociation (SD) is another clinical picture, which is often related to traumatic experiences, especially child sexual abuse [30,31] or exposure to cumulative trauma and bodily threat [32]. Nijenhuis and colleagues introduced the concept of SD, referring to dissociative symptoms, which phenomenologically involve the body, and comprise a reduction up to a complete loss of sensory perception and/or motor control, as well as involuntary perception of sensory (e.g., prickling), motor (e.g., tremors) and/or pain symptoms [33]. The appearance of such symptoms, after prolonged and repeated trauma, can be explained by the concept of the defense cascade: existential threats first prompt excessive physiological arousal (to prepare the organisms for fight/flight responses). Upon lack of escape options, this arousal turns into immobility due to activation and inhibition of particular functional components as a last way out when faced with an inescapable threat [34,35,36]. Those recurring response patterns in the limbic system are tied in with the original trauma, and are reactivated in contexts of high arousal, even if the danger has already passed [35]. (Schroder, 2018)

Dissociative disorders diagnoses

Most participants reported being professionally diagnosed with dissociative disorders (F44 in ICD-10) and experiencing dissociative personality states (indicating DID or DDNOS). This result is also corroborated by the outcomes of the psychometric psychopathological measures on trauma-related symptom severity in the current study, which show indications of PTSD (operationalized by PCL-5) and clinically-relevant SD (operationalized by SDQ-5) in most of the participants. The high psychic strain of the current sample, reflected by psychometric measures as well as reported prevalence rates of psychiatric diagnoses, is in line with the evidence-based impact of child sexual abuse on (C)PTSD and dissociative disorders [68] and with reports of professionals who treat ORA victims [19,69]. The reported prevalence rates are further in line with previous research that demonstrated a strong relationship between childhood trauma and the development of borderline personality disorders [70], eating disorders [71], PTSD and depression [39]. Under the previous assumption that the current sample of self-identified ORA victims may be relatively viable, the psychic strain is alarming. The reported prevalence rates of wrong or inaccurate diagnoses of psychiatric disorders by health care professionals in the current sample are led by Emotionally Unstable or Borderline Personality Disorders (BPD) and Schizophrenia. (Schroder, 2018)

ORA, CSA and PTSD

Previous research suggests a plethora of promotive and protective factors in childhood that influence the development of or resilience to psychic strain, consisting of individual (e.g., psychological) and environmental (e.g., parenting and peer) factors [37]. Exposure to CSA leads to psychopathology and psychiatric morbidity [38]. A meta-analysis of the published research on the effects of CSA revealed an average weighted effect of d = 0.40 for PTSD, whereby gender, socioeconomic status, type of abuse, age when abused, relationship to perpetrator, and number of abuse incidents, were not found to influence this effect [39]. The authors therefore rather adopt a multifaceted traumatization model, discarding a specific sexual abuse syndrome in the context of CSA. However, a more recent study found that children who were sexually abused by relatives develop more severe PTSD symptoms [40]. Further, a recent study revealed that PTSD correlates with somatization in sexually-abused children, whereby this effect was shown to be moderated by the type of abuse [41]. Some studies revealed evidence on associations between ORA experiences and trauma-related psychopathology in individuals who reported this particularly severe and prolonged form of CSA [19,42,43]. (Schroder, 2018)

PTSD, trauma and dissociation

DID reported by the participants is associated with increased PTSD and SD symptoms. This is in line with [22], who revealed empirical evidence suggesting that a clinical level of dissociation correlates with higher CPTSD symptoms. The authors see dissociation as an organizing construct within CPTSD. The results of the current study further revealed that a reported exit out of the ORA structures decreases PTSD and SD symptom severity. It makes sense that trauma-related symptoms ameliorate when the damaging influences of the perpetrators have disappeared. The results further suggest that the use of (pseudo-)ideological strategies by the perpetrators, that is, according to our definition, ritual abuse, increases trauma-related symptom severity. (Schroder, 2018)

Public advocacy, public education, survivor training, and the building of a research base to help survivors and their helpers

 Solutions to decrease and eliminate these difficulties will be discussed.  These will include public advocacy, public education, survivor training, and the building of a research base to help survivors and their helpers move forward to prevent these difficulties in the future.

Describe ways ritualistic abuse survivors and their helpers can change the present system to increase services for these survivors.

Political changes – educating elected officials, insurance changes, working with the media, building safe and healthy support systems, improving social services, improving mental health educational programs.

Training Others, Support Options

Opportunities for Trauma-informed Clinicians to provide Training for Other Clinicians –

 At universities and colleges, Serve as a guest speaker in a class.

Teach a class on trauma and dissociation

Integrate material on trauma and dissociation in other classes

At professional conferences

Volunteer to do presentations (Noblitt – Teaching 2024)

 However, it is notable that research with patients who disclose organised abuse or characteristics of abuse associated with it (such as multiple perpetrators, sexual abuse by women as well as men, and/or very early sexual abuse initiation) has consistently found higher levels of psychopathology and psychosocial impairment compared with other sexually abused populations. Despite the complex needs of this group, they are frequently unable to access integrated and effective care. Some support is being provided by sexual assault services, domestic violence services and supported accommodation programs, but these interventions are often ad hoc and crisis orientated (Cooper, 2004). Many survivors end up in prison or homeless, chronically disabled by illness, or dead. It is clear that further research and investment in specialist treatment and support options for this population is necessary to address the challenges posed by organised abuse. (Salter, 2012)

References

Grossman, S., Cooper, Z., Buxton, H., Hendrickson, S., Lewis-O’Connor, A., Stevens, J., Wong, L.-Y., & Bonne, S. (2021). Trauma-informed care: recognizing and resisting re-traumatization in health care. Trauma Surgery & Acute Care Open, 6(1). https://doi.org/10.1136/tsaco-2021-000815

Heboyan, V., Douglas, M. D., McGregor, B., & Benevides, T. W. (2021). Impact of Mental Health Insurance Legislation on Mental Health Treatment in a Longitudinal Sample of Adolescents. Medical Care, 59(10), 939–946. https://doi.org/10.1097/mlr.0000000000001619

Kolis, K & Houston-Kolnik, J   (2018) Trauma Types and Promising Approaches to Assist Survivors. ICJIA Research Hub. Illinois Criminal Justice Information Authority Icjia.illinois.gov.  https://icjia.illinois.gov/researchhub/articles/trauma-types-and-promising-approaches-to-assist-survivors

Noblitt, R (2024) Extreme Abuse Survivors as an Underserved Community. Survivorship Journal, ISSN 046-2015 Summer 2024,Volume 28, Issue 2 https://survivorship.org/notes-and-journal   

Noblitt, R (2024) Teaching Trauma and Dissociation in Higher Education – PowerPoint and Presentation, The Survivorship Trafficking and Extreme Abuse Online Conference 2024 https://survivorship.org/the-survivorship-trafficking-and-extreme-abuse-online-conference-2024-presentations

Noblitt, R (2024) Trauma-Informed Care. Survivorship Journal, ISSN 046-2015 Winter 2024, Volume 28, Issue 1  https://survivorship.org/notes-and-journal/    

Sachs, A (2024) Attachment Relationship in DID: Survival, Destruction and Healing. 2024 Online Annual Ritual Abuse, Secretive Organizations and Mind Control Conference PowerPoint  https://ritualabuse.us/smart-conference/2024-conference/2024-conference-video-presentations-and-powerpoints/

Salter, M., & Richters, J. (2012). Organised abuse: A neglected category of sexual abuse with significant lifetime mental healthcare sequelae. Journal of Mental Health, 21(5), 499–508. https://doi.org/10.3109/09638237.2012.682264

Schröder, J., Nick, S., Richter-Appelt, H., & Briken, P. (2018). Psychiatric Impact of Organized and Ritual Child Sexual Abuse: Cross-Sectional Findings from Individuals Who Report Being Victimized. International Journal of Environmental Research and Public Health, 15(11), 2417. https://doi.org/10.3390/ijerph15112417