Transcript 'Healing the Wounds of Sexual Assault: Practical
HEALING THE WOUNDS OF SEXUAL ASSAULT: PRACTICAL STRATEGIES FOR WORKING WITH VICTIMS ACROSS THE LIFESPAN
Patricia Taimanglo, Ph.D.
Lilli Perez, Ph.D.
Rosemarie Camacho, M.A
.
SAARCA Guam Sexual Assault and Abuse Resource Center Association
Acknowledgements
Guam Sexual Assault and Abuse Resource Center Association (SAARCA) Funding from Governor’s Community Outreach Federal Programs Office Ellen Bez, M.D.
Attended APSAC conference in July 2011 Project Karinu supported Dr. Perez’s attendance Healing Hearts Crisis Center Local statistics AIMFT Wayne Butler registration University of Guam: Joan Swadell facility
The American Professional Society on the Abuse of Children 19
th
Annual Colloquium Philadelphia, PA July 13-16, 2011
APSAC 19
th
Annual Colloquium
93 institutes and workshops which addressed all aspects of child maltreatment: prevention, assessment, intervention treatment with victims, perpetrators and families affected by physical, sexual and psychological abuse and neglect Cultural considerations
APSAC 19
th
Annual Colloquium
Seminars designed primarily for professionals in: mental health, medicine and nursing, law, law enforcement, education, prevention, research, advocacy, child protection services, and allied fields Educational goal: foster professional excellence in the field of child maltreatment by providing interdisciplinary professional education
Background
Dr. Taimanglo, Clinical Psychologist DMHSA Private Practice Dr. Lilli Perez, Clinical Director, Project Kirinu Private Practice Rosemarie Camacho, IMFT Substance Abuse Counselor
Background
ALL have been providing individual and family therapy to victims of sexual assault for at least five years Healing Hearts Crisis Center
Clients who come in due to other concerns
but have history of sexual assault
e.g. dual diagnosis of substance abuse and PTSD due to sexual assault
Agenda
Local Statistics on Sexual Assault serves as a backdrop for all three presentations most clients we see were victimized as children Dr. Perez will cover working with children Rosemarie will cover working with adolescents Dr. Taimanglo will cover working with adults
Agenda
We will each cover: general assessment of the experience not assessment tools not forensic interviewing therapeutic techniques used in practice based on training and experience working with victims Knowledge, skills, techniques learned at the conference emphasis on culturally relevant application Experiential activities FUN!
Timeline:
1:00 – 1:15: 1:15 – 2:15: 2:15 – 2:25: 2:25 – 3:15: 3:15 – 3:45: 3:45 – 4:00 Introduction and Local Statistics Dr. Perez - Children Break Rosemarie Camacho – Adolescents Dr. Taimanglo - Adults Question and Answers
LOCAL STATISTICS ON SEXUAL ASSAULT
Who are the victims?
Who are the perpetrators?
Healing Hearts Crisis Center
Age groups for 2004 - 2008
Healing Hearts Clients 2004-2008
Minors: Population 2009-2010
Gender Served 2009 - 2010
Ethnicity of victims for 2008
Population by Ethnicity for 2009
Filipino 4% Caucasian 3% Unknown 5% Palauan 1% Japanese Chuukese 16% Chamorro 48% Mixed 21%
Population by Ethnicity for 2010
Caucasian 1% Unknown 8% Japanese 1% Colombian 1% Mixed 28% Chamorro 47% Chamorro Chuukese Filipino Yapese Mixed Unknown Caucasian Japanese Colombian Yapese Filipino 2% 4% Chuukese 8%
Relationship to Offender (2008)
Relationship to Offender
Relationship To Offender 2009-2010
14% 17% Family Known Unknown 69%
WORKING WITH ADOLESCENT VICTIMS OF SEXUAL ASSAULT
Rosemarie B. Camacho, M.A., IMFT
Working with Adolescents
Adolescents can be anywhere from 11 to 21 years Varying degrees of physical/emotional/intellectual maturity dictates whether to us child/adolescent/adult resources and materials usually “round up”
Working with Adolescents
Most were abused as children somewhere between 7 and 13 Many referred to school counselor and/or DMHSA for cutting and/or suicidal ideations, then disclose childhood sexual abuse e.g. 14 year old Chamorro girl referred to school counselor for cutting, then discloses being abused by older cousin when she was between 9 and 11
ASSESSMENT
What happened?
How has it affected the client?
How has it affected family?
Parent Interview
Begin with Parent Interview Victim may not even come to the 1 st appointment or may meet for a few minutes at the end Parent Interview may take up part of the second session Helps the client get comfortable Psychosocial Interview Medical Concerns Family Structure School performance Any known self-harm behaviors
Parent Interview
Discuss privacy Mandatory reporting requirements Child’s privacy Reasonable degree Importance of trusting relationship Will share any concerns of potential danger Ongoing Drug Use Illegal Behaviors Inappropriate relationship
Parent Interview
Strengths When does he/she seem the happiest, the most calm, relaxed?
#1 answer . . .
When she’s with her friends If behavioral concerns . . . When is she the most respectful, responsible, etc.?
#1 answer: When she wants something!
Parent Interview
Goals How will we know when things are better?
When she’s more open, smiling more When she’s more respectful, more responsible #1 indicator that makes parents happy: When her grades are up Others: Does her chores Communicates more respectfully Discuss importance of realistic goals Put out the “big fires” Accept normal behaviors among adolescents
Parent Interview
What are some of his/her strengths?
that we can build upon to meet our goal loves to read, listen to music, writing, art, etc.
Hobbies, interests STRONGLY encourage organized sports, dance, clubs, etc.
Keep life as normal as possible not punish the victim further Help to “compartmentalize” Open up a new chapter WHO are some strengths in your child’s life Grandparent, cousins who are doing well, etc.
Parent Interview
Effects of the assault: How has this affected your child?
Nightmares, hypervigilance, self-harm, suicidal ideations, withdrawal Child checklist of characteristics When (if at all) did you notice a change?
Often in hindsight Got quiet and sad or angry and defensive easily agitated withdrew from the family normalize adolescent behavior
Parent Interview
Noticable changes: Often made cryptic remarks, emotional outbursts “You don’t understand what I’ve been through!” Often tried to avoid contact with abuser I hate going over there!
Excessive resistance E.g. I finally asked her, “Did something happen, did someone touch you? and she just started to cry. and that’s when I knew”
Assessment/Psycho-education
General Assessment of the victimization and resulting experience “Assessing the damage” while also conducting psycho-education/making recommendations about what can make the experience less or more traumatizing aka “buffers”
1) Physical aspects of the assault
severity: mild-moderate-severe E.g., force or penetration vs. exposure to pornography single incident vs. multiple incidents WHERE did the assault take place?
Victim’s home? sometimes recommend changing rooms or re-decorating
Assessment/Psychoeducation
2) Relationship of perpetrator to victim
parent/caregiver vs. stranger or acquaintance How emotionally close? favorite uncle, older cousin who was like a brother, etc.
Closer the relationship, the more traumatizing Incest cases often most damaging but also depends on other “buffers” Case example: teenage girl forced into incestuous relationship with biological father that she met at13 years old.
Very positive outcomes
Assessment/Psychoeducation
First two are “fixed” what happened, who did it?
“What’s done is done” Able to guesstimate whether client will need short term or long term therapy combined with psychosocial interview Other traumatic experiences Strengths Social support network Next factors include parent recommendations crucial in the healing process
Assessment/Psychoeducation
3) Emotional Support Does the parent believe and support the child?
Caution against “blaming victim” for not telling, etc.
Do other family members and friends believe and support the child?
Easy when abuser is a stranger more complicated when it’s a family member e.g. 14 year old girl abused by mother’s boyfriend brought by grandparent who has temporary guardianship because mother doesn’t believe her and is still in a relationship with the abuser worse when parent believes sexual contact occurred but blames the child for provoking it
Assessment/Psychoeducation
“Ripple Effect” of disclosure is often more traumatizing than the abuse itself e.g. 11 year old girl abused by 17 year old cousin while they were at grandparents’ house. Was very close with abuser’s 12 year old sister, but now she is not talking to victim because she “put their brother in jail” de-friended on Facebook putting cryptic messages on her wall Mom and her sister (abuser’s mother) are no longer speaking, etc.
Grandma’s is crying, doesn’t know who to believe
Assessment/Psychoeducation
“Ripple Effect” broken relationships moving around changing schools family Conflict Victim always feels responsible for the “ripple effect” Often regrets telling Often the cause for recantations didn’t mean to break up the family Emphasis on “Who threw the rock?”
Assessment/Psychoeducation
4) Sense of Justice (related to emotional support) Focus of anger, blame appropriately placed on perpetrator Perpetrator held accountable legally Jail time, mandatory counseling, etc.
socially Ostracized from the family “karma” “Ti mamaigo si Yu’os”
TREATMENT
Treatment
Healing Heats Crisis Center 6 sessions including Parent Interview Request extension, as needed majority need more than 6 Normalization You’re not alone 1 in 3 girls are abused by the time they are 18 “count off in PE”
Treatment
Analogy of Boil/Abscess Ask about any scars they have Tell me how you got that scar Does it hurt now? You never forget how you got the scar, but it doesn’t hurt anymore All traumatic experiences are like an open wound until you heal Difference between a wound and a boil Grandpa died: like breaking your arm Not ashamed of the wound, not afraid to seek support
Treatment
Sexual abuse: Boil/Abscess Hide the wound, ashamed of it, feel dirty Try to treat it yourself, but it just keeps getting worse, infected Every day bumps and touches hurt Treatment: Hibiscus Flower or Warm Compress Treat it gently, get the infection out It gets ugly, gross, but then heals Leaves a scar for a while Harry Potter scar stings from time to time
Treatment
Juvenile Interview: Establishing Rapport, Trust, Comfort Similar to parent interview What do people like about you?
What might some people not like about you?
What do you like about each member of your family?
What do you wish was different about each of them?
Same question for friends Drugs and alcohol (rarely reported) Other sexual experiences (rarely reported)
Treatment
Traumatic Screening: 3 most difficult experiences Sexual Assault may not be the most traumatizing Ripple effect often more traumatizing 3 Best Experiences: Best things that have happened to you Accomplishments you are most proud of Suicidal Ideations – Scale of 0-10 0-5 – thoughts with no intent 6 increasing thoughts of intent – when, where, how
Treatment
Primary Resource:
It Happened to Me: A Teen’s Guide to Overcoming Sexual Abuse
Approximately 50 exercises Includes writings by adolescent survivors Utilize between 4 and 6 1-2 per session
Treatment
1. Your Feelings - What do they mean?
Normalization of reactions to sexual abuse Confusion, shock, guilt, paranoid, disgust, denial, anger, shame, nausea, betrayal, fear Usually see a sigh of relief or moment of realization that they are not alone Which emotions did you experience at the time of the abuse?
Looking back, when did you first start to feel uncomfortable?
Body/Mind warning system Healthy Boundaries: Going with your gut!
Which did you experience immediately after?
Which do you still experience now?
Treatment
2: Family Messages
Usually if the abuser is a family member My Mother/Father always says . . .
“Family is more important than anything else” “Don’t shame the family” Cultural beliefs, value of interdependence Sacrifice personal needs for family needs Messages about girls and boys “Nice girls stay quiet” “Do what your brother says” Family messages I would like to pass on . . .
Family messages I would like to throw away . . .
Treatment
2: Family Messages (continued)
Messages about children and adults “Respect your elders!” In each category, ask about the messages they received and how it affected the experience ability to resist or speak up Often blame self for letting it happen or not reporting sooner Validate the experience Work through guilt and learn to let go
Treatment
Exercise 3: Uncovering Emotional Manipulation
Some of the ways abusers manipulate or “trick” their victims He threatened to hurt someone if I told anyone He told me it would ruin the family if I told He would talk about what “we” were doing, as if I wanted it to happen.
Other forms of manipulation: Preventing you from talking to others, isolating you Buying you gifts to keep you quiet Putting restrictions on you if you resist E.g. victims who were isolated by mom’s boyfriend so he could abuse them. Once while fondling them said, “Don’t worry, I’ll never molest you” In what ways were you manipulated?
Discuss recognizing future manipulation Go with your gut!
Treatment
Exercise 4: Anger Gone Mad Discuss difference between healthy anger and “going mad” Anger: Healthy Boundaries Mad: Going crazy, excessive fear, irrational thinking, loss of control, revenge Give permission to be angry over what happened Use healthy anger, assertive communication to protect boundaries Let go of hatred and rage Especially projected on to others
Treatment
Exercise 5: Being Completely Young
When you were younger, what did you think adolescence would be like?
More freedom, driving, have a boyfriend, wear makeup etc.
Victims often feel abuse “ruined the best years of my life” Broken relationships at home Going to counselors and doctors Worrying about what people will think Adults look back at adolescence as the best time in their life Includes learning to give and receive support from friends and family during rough times.
Some things I have missed out on because of my trauma are . . .
Some ways I am stronger because of my trauma are . . . .
Treatment
Teen-Esteem Cards Body Image, Things I’m good at, I’m a good friend because . . .
Family Activity: Life Stories Usually encourage parents to tell other siblings what happened 90% of the time other kids know more than they think Often in state of anxiety over “elephant in the room” Briefly address the abuse Your family has a story, made up of little stories The day your parents met The day you were born This is just one chapter in your family’s story All family stories have sad chapters, scary chapters, funny chapters, but we always have a happy ending
Treatment
Teen-Esteem Cards Family Activity: Life Stories Usually encourage parents to tell other siblings what happened 90% of the time siblings know more than parents think Often in state of anxiety over “elephant in the room” Briefly address the abuse Quick safety talk with siblings about “going with their gut” Your family has a story, made up of little stories The day your parents met The day you were born This is just one chapter in your family’s story All family stories have sad chapters, scary chapters, funny chapters, but we always have a happy ending Sample cards: Tell a story about a time you were proud Celebration of each family member
Treatment
Termination Suspend counseling until further issues arise Follow up Time to testify Further contact with GPD, AG’s Office “Ripple Effect” issues Run into the perpetrator and his/her family
LESSONS LEARNED
APSAC CONFERENCE JULY 2011
Lessons Learned
APSAC Conference Effects of early victimization may not manifest until adolescence, etc.
Child victims often do not seem traumatized May seem fine as children Treatment may be brief
What I learned at the Conference
Adolescence: Start to have consensual sexual experiences Difficulty distinguishing between healthy sexuality and abusive sexuality Higher level, more sophisticated thinking: Start to appreciate the seriousness or severity of the childhood abuse Ask parents to follow up when they are teenagers May explain local data between 13 and 17 at time of report but 5-10 at time of abuse
Lessons Learned
Importance of helping the victim tell the story, in detail Historically have brushed over the story and emphasized the effects Brain associates memories, pictures, triggers associated with the abuse with fear, being unsafe, Anxiety: flight or fight response Provide corrective experience Tell the story in a place and with a person associated with safety, nurturing, etc.
Lessons Learned
Conference was focused on children Bubbles, pinwheels can be used to practice deep breathing, grounding techniques while telling the story Encourage the child to tell the story in as much detail as possible Similar to exercises Dr. Gil and Dr. Lizama were describing at Veteran PTSD training Take the “power” out of the experience Reduce risk of harmful behaviors used to avoid or cope with triggers Drugs, alcohol, cutting, etc.
Lessons Learned
Experiential Activity: Pinwheel Think of a scary incident in your life Car accident, etc.
Tell the story in as much detail as possible Pay attention to body cues When you start to feel discomfort Inhale for at least five seconds Exhale for at least five seconds I’m okay, I’m safe now Or some other calming, comforting message
Pinwheel Activity
Cognitive Behavioral Approach Positive Self-talk Grounding Visualization Meditation Can help with insomnia Pinwheels are glow in the dark
TREATMENT RESOURCES
for Children, Adolescents, Adults
Treatment Resources for Children
Group Treatment for Sexually Abused Children Joan Golden Mandell; Linda Damon Helping Your Child Recover from Sexual Abuse Caren Adams; Jennifer Fay Therapeutic Exercises for Children: Guided Self Discovery Using Cognitive Behavioral Therapy Robert, Barbara, and Rebecca Friedberg Real Life Heroes - A Life Storybook for Children Richard Kagan, Ph.D.
How Are You Peeling?
Freyman and Effers
Treatment Resources for Children
Paper Dolls/Paper Airplanes Crisci, Lay, Lowenstein Too Scared to Cry Lenore Terr Self-Esteem Cards Children (DAISY) The Grandmothers Club Finding Sunshine After the Storm McGee and Holmes A Terrible Thing Happened Holmes, Mudlaff, Pillo Helping Your Child Recover from Sexual Abuse Life Stories (Game) TaliCor The Ungame Fat Brain Toys Sticks and Stones
Treatment Resources for Adolescents
It Happened to Me Wm. Lee Carter, Ed.D.
The Me Nobody Knows Barbara Bean and Shari Bennett Self-Esteem Cards TEEN ESTEEM The Grandmothers Club Adults (SELF-ESTEEM)
Treatment Resources for Adults
The Courage to Heal: A Guide To Women Survivors of Child Sexual Abuse Allies in Healing: When the Person You Love Was Sexually Abused as a Child Ellen Bass and Laura Davis The Survivor’s Guide to Sex Haines Surviving Childhood Sexual Abuse Workbook Ainscough and Toon
Treatment Resources for Adults
Healing the Incest Wound Courtois Collaborative Healing: A “Shorter” Therapy Approach for Survivors of Sexual Abuse Hirschfiel and Cody Working with Adult Incest Survivors: The Healing Journey Kirshner, Kirschner, Rappaport
Treatment Resources for Adults
Creative Group Therapy for Women Survivors of Child Sexual Abuse: Speaking the Unspeakable Boundaries: When to Say Yes, How to Say No to Take Control of Your Life Cloud and Townsend Self-Esteem Cards SELF-ESTEEM The Grandmother’s Club
Feedback
What worked 1.
2.
3.
1.
2.
3.
What didn’t work 1.
2.
3.
What do you want to see next time?