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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
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
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
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
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 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
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