Trauma Informed Care for Victims of Intimate Partner Sexual Assault

By Sally J. Laskey, Associate Director, National Sexual Violence Resource Center

**This material is adapted from the forth coming National Sexual Assault Response Team (SART) Toolkit.

Introductory Message:

“When a person is harmed by a criminal act, the agencies that make up the criminal and juvenile justice systems have a moral and legal obligation to respond. It is their responsibility not only to seek swift justice for victims, but to ease their suffering in a time of great need.” (OVC, 2000)

Sexual assault trauma is a physical and emotional violation that may result in feelings of intense fear, powerlessness and hopelessness. Such events can be traumatic not because they are rare, but because they overwhelm the internal resources that give individuals a sense of control, connection and meaning. (Bryant-Davis, 2005). Research indicates that women who are physically abused by their partners are at high risk for sexual violence. (Bergen, 2006; Campbell, 1989) It is estimated that over 7 million women have been raped by their intimate partners in the United States. (Tjaden & Thoennes, 1998)

Intimate partner sexual assault is a complex, multifaceted problem that no one person or agency can fully resolve alone. Since victims’ issues are multidimensional (e.g., physical, mental, economic, legal, spiritual, emotional), and can impact a range of individuals within the community, coordination of efforts that brings a team of trained providers together to help victims, their friends and families and the community for as long as services are needed are paramount. Additionally, those that work with victims of trauma may experience vicarious trauma as a result of their work with sexual assault victims. Symptoms of vicarious trauma are similar to those experienced by individuals with Post Traumatic Stress Disorder and include numbing, hypervigilance, sleep difficulties and intrusive thoughts of traumas described by victims. Developing trauma informed care includes incorporating supports that lessen the likelihood of vicarious trauma in victim service professionals.

This forum will explore the provision of trauma-informed care to survivors of intimate partner sexual assault with specific attention to the role of multidisciplinary teams.

Introduction:
Rape survivors represent the largest non-combat group of individuals with post traumatic stress disorder (PTSD). (Campbell and Wasco, 2005) When rape victims disclose their assault(s) they often risk disbelief, scorn, shame, punishment and refusals of help. (Kilpatrick and Seymour, 1992).

Due to these fears, the pain of sexual violation is extremely isolating. Victims often question themselves and distrust the world around them. First responders need to understand the complex issues that victims face and provide compassionate and emotionally supportive care.

Trauma has both objective and subjective aspects. It is useful to think of all trauma symptoms as adaptations. Symptoms represent a victims’ attempt to cope the best way they can with overwhelming feelings. Severe trauma can have a major impact on the course of victims’ lives. For example, rape victims were 4.1 times more likely than non-crime victims to have contemplated suicide and 13 times more likely to make a suicide attempt. (Kilpatrick et al 1992) Victims of intimate partner sexual violence are often even more isolated and unlikely to reach out for services since they may view the world as an unsafe place, distrust others, have difficulty with decision-making. Victim service providers trained in trauma responses and trauma informed care can help victims work through a wide range of emotional reactions and help them with their healing.

Defining Trauma-Informed care:

“Trauma-informed” services are not specifically designed to treat symptoms or syndromes related to sexual or physical abuse or other trauma, but they are informed about, and sensitive to, trauma-related issues present in survivors. A “trauma-informed” system is one in which all components of a given service system have been reconsidered and evaluated in the light of a basic understanding of the role that violence plays in the lives of adults, children and adolescents and families or caregivers seeking mental health and addictions services (Harris & Fallot, 2001). A “trauma informed” system uses that understanding to design service systems that accommodate the vulnerabilities of trauma survivors and allows services to be delivered in a way that will avoid inadvertent retraumatization and will facilitate consumer participation in treatment. It also requires, to the extent possible, closely knit collaborative relationships with other public sector service systems serving these clients and the local network of private practitioners with particular clinical expertise in “traumatology” (Harris & Fallot, 2001).

Elements of Trauma Informed Care:

Trauma informed approached focus on understanding a person’s history and the entire context of their experience. It emphasizes safety, choice, empowerment, and cultural competence. Elements of trauma informed strategies include:

• Focus on understanding whole individual & context
• Focus on trust and safety
• Trauma knowledge, awareness/sensitivity instilled at all levels of system
• Prevention-oriented
• Strengths-based, resilience & healing-oriented
• Collaborative: use of non-traditional and expanded community supports
• Facilitates growth, resilience, healing, and empowerment
• Culturally-competent/sensitive services
• Is sensitive to and seeks to minimize re-victimization/re-traumatization in all aspects of service delivery.
• Victim choice & control Maximized-Individualized service delivery






Key Elements:

Cultural Competence
Policies, procedures, staff, and services are sensitive to the cultures, traditions and beliefs of all community members.

Trauma Competence
Policies, procedures, staff and services are aware of and informed by the unique experiences and needs of trauma survivors.

Safety
Both physical and emotional safety of victims is considered through non-judgmental treatment, informed consent practices and holistic care. Additionally, trust is built between providers and victims through consistency, accessibility and clear role delineation.

Collaboration
Policies and practices encourage empowerment and partnership with victims, multidisciplinary team members and involve strength-based, community specific approaches.
Adapted from Maine Department of Health and Human Services.



Some specific recommendations for multidisciplinary responders:

• Be aware that victims may know little about the criminal justice system and may find it intimidating,
confusing or frightening;
• Let victims decide when and where they want to talk;
• Provide as much information as possible regarding the investigative process;
• Give victims information to help them make informed decisions; and
• Have a list of community referrals readily accessible.

To help service providers respond to victims‟ concerns, a 13 minute video, Listen to My Story: Communicating With Victims of Crime, highlights the fundamentals of communicating with victims, including helping victims regain control, listening with compassion, understanding the impact of trauma, building trust, and overcoming communication barriers. A discussion guide for the video can be downloaded. http://www.archive.org/details/gov.doj.ncj.195655

Considerations for Law Enforcement and Prosecution:

Recovery is a process in which victims work through an onslaught of disturbing physical, mental, emotional and spiritual concerns. Victims often struggle with a perception that they are different or not normal due to the assault. Victim responses to sexual assault are uniquely individual and extremely varied. For example, some of the responses may include continued contact with perpetrators, delayed responses, flat affects or use of humor. Although lay people (e.g., jurors) may perceive these responses as counterintuitive, they are very common responses to trauma. In an effort to educate prosecutors and other allied professionals about common myths regarding sexual assault, the National Center for Prosecution of Violence Against Women at the American Prosecutors Research Institute (NCPVAW) published an article, Explaining Counterintuitive Victim Behavior in Domestic Violence and Sexual Assault Cases. (2007: Volume 1 Number IV) http://www.ndaa.org/publications/newsle ... tents.html

NCPVAW has also published a monograph entitled Introducing Expert Testimony to Explain Victim Behavior in Sexual Assault and Domestic Violence Prosecutions http://www.ndaa.org/publications/apri/v ... women.html

Considerations for health care providers:

Individuals that experience sexual assault by an intimate partners victims present a wide range of symptoms to healthcare practitioners, such as skipping or racing heart, dizzy spells, headache, muscle tension in the neck and head, faintness or light headedness, chest pressure, hyperventilation, smothering or choking sensation, lump in the throat, tingling or numbness, nausea, vomiting, diarrhea, sweating unrelated to temperature conditions, hot flashes, chills, shaking or trembling of hands and legs, rashes resulting from excessive sweating, and sensitivity to light, sound, touch, temperature and taste. Victims can also experience adrenalin rush, sleepiness, unexplained crying, physical or emotional numbness, feelings of being trapped, helplessness, panic reactions, nightmares, flashbacks, racing thoughts, heightened or dulled perception, complete or partial amnesia, thoughts of suicide, eating problems/disorders, substance abuse or self-mutilation. Mental health counselors and rape crisis advocates who understand the impact sexual assault can be a helpful support. For example, some survivors use drugs or alcohol to self-medicate due to the pain of sexual assault. If a counselor does not understand the impact of sexual assault, they may see alcohol or drug use as the most serious problem in that survivor’s life and may not do victim-centered counseling focusing on the impact of sexual assault.

In addition, sexual violence is linked to numerous adverse chronic health conditions such as arthritis, chronic neck or back pain, frequent migraines or other types of headaches, visual problems, sexually transmitted infections, chronic pelvic pain, increased gynecological symptoms, peptic ulcers, and functional or irritable bowel disease. Health care providers in collaboration with victim advocates can develop protocols for medical professionals for treatment, referrals and reporting. Hospitals can establish training programs and protocols for all hospital personnel on the rights and needs of sexual assault victims. Additionally, SARTs or other multidisciplinary teams can develop a victim-sensitive code of ethics with special consideration for victims’ needs such as food, clothing and transportation. Coordinated agencies can be a gateway to assistance for victims, prioritizing confidentiality and privacy needs while providing seamless referrals for their emotional, mental, legal, medical, spiritual and practical needs, regardless of which agency responds first. On a systems‟ level, teams can work to provide seamless local services by addressing:

• The kinds of services that are provided by medical professionals and institutions in their community;
• The need for healthcare protocols and training, including medical forensic exams and follow-up medical care;
• Issues specific to sexual abuse of elderly victims and individuals with disabilities; and
• Cross-cultural service delivery, including campus health services, military medical providers, and native
healers.

See the The National Protocol for Sexual Assault Medical Forensic Examinations for guidelines at http://www.safeta.org/.

Where do we go from here and how do we stay healthy as we do trauma work?
What individual practices do you have in place that are trauma informed?
What organizational practices do you have in place that are trauma informed?
What cross-system practices are utilized in your community that are trauma informed?
How are you incorporating survivor needs and feedback into your development of trauma informed care?
Have you discussed vicarious trauma in your community and the impact on effectiveness?
Who are the trauma experts in your community and do you have relationships with them?

This guidebook presents one way in which a community can address vicarious trauma. It shows both the impact of trauma work on victim service professional and provides some potential solutions.
Guidebook on Vicarious Trauma: Recommended Solutions for Anti-Violence Workers. http://www.phac-aspc.gc.ca/ncfv-cnivf/f ... auma_e.pdf

I look forward to the discussion and sharing of ideas.



References

Bergen, R. (2006, February). Marital Rape: New Research and Directions. Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence. Retrieved February 13, 2009, from: http://www.vawnet.org.

Bryant-Davis, T. (2005). Thriving in the Wake of Trauma: A Multicultural Guide, CT: Praiger Publishers, p. 2-3.

Campbell, J. C. (1989). Women’s responses to sexual abuse in intimate relationships. Health Care for
Women International, 10, 335-346.

Campbell, R. & Wasco, S. (2005). “Understanding Rape and Sexual Assault: 20 Years of Progress and Future Directions,” Journal of Interpersonal Violence, 20(1), p. 127-131.

Harris, M., & Fallot, R. (2001). Using trauma theory to design service systems. New Directions for Mental Health Services, 89. Jossey Bass.

Kilpatrick, D. & Seymour, A. (1992). Rape in America: A Report to the Nation, Arlington, VA: National Victim Center.

Tjaden, P., & Thoennes, N. (1998). Prevalence, incidence and consequences of violence against women:
Findings from the national violence against women survey (NCJ 172837). Washington, DC: U.S. Department of Justice.

Thank you for coming to the forum. Please post any ideas or questions that you have!

Sally