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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. Guam Sexual Assault and Abuse Resource Center Association SAARCA

Patricia Taimanglo , Ph.D. Lilli Perez, Ph.D. Rosemarie Camacho, M.A

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Healing the Wounds of Sexual Assault:  Practical Strategies for Working with Victims Across the Lifespan. SAARCA. Guam Sexual Assault and Abuse Resource Center Association. Patricia Taimanglo , Ph.D. Lilli Perez, Ph.D. Rosemarie Camacho, M.A . Acknowledgements. - PowerPoint PPT Presentation

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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.

Guam Sexual Assault and Abuse Resource Center AssociationSAARCA

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

19th Annual Colloquium

Philadelphia, PAJuly 13-16, 2011

APSAC 19th 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 19th 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

AgendaWe 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: Introduction and Local

Statistics1:15 – 2:15:  Dr. Perez - Children2:15 – 2:25: Break2:25 – 3:15: Rosemarie Camacho –

Adolescents3:15 – 3:45: Dr. Taimanglo - Adults3:45 – 4:00 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

Chamorro48%

Mixed21%

Chuukese16%

Unknown5%

Filipino4%

Caucasian3%

Palauan1%

Japanese1%0%0%0%0%0%0%0%0%0%0%

Population by Ethnicity for 2010

Chamorro47%

Chuukese8%Filipino

4%Yapese2%

Mixed28%

Unknown8%

Caucasian1%

Japanese1%

Colombian1%

ChamorroChuukeseFilipinoYapeseMixedUnknownCaucasianJapaneseColombian

Relationship to Offender (2008)

Relationship to Offender

Relationship To Offender 2009-2010

69%

14%

17%

FamilyKnownUnknown

Rosemarie B. Camacho, M.A., IMFT

WORKING WITH ADOLESCENT VICTIMS OF SEXUAL ASSAULT

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

ASSESSMENTWhat 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 1st

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”

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/Psycho-education

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

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?”

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”

Assessment/Psychoeducation

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 . . .

Treatment2: 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!

TreatmentExercise 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

TreatmentExercise 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

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 Children

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 Adolescents

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

Treatment Resources for Adults

What worked1.2.3. What didn’t work1.2.3.What do you want to see next time?1.2.3.

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