Base knowledge and introduction to trauma informed framework

A brief overview and working definition of sexual abuse, details of common impacts, introduction to gender analysis, improved coping, a basic trauma informed care framework, and notes on the value of group work.

Child sexual abuse

Child sexual abuse involves a child in sexual activity or behaviour, instigated by an adult, adolescent, or another child. It is a betrayal of trust by someone, usually by an adult or older peer, where there is an imbalance of interpersonal power. A variety of definitions exist. The World Health Organization (WHO, 2014) defines child sexual abuse as the involvement of a child in sexual activity that:

“The child does not fully comprehend; cannot give informed consent to or is not developmentally prepared for and cannot give consent. It involves activity between a child and an adult, or another child who by age or development is in a relationship of responsibility, trust or power. Child sexual abuse can include the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of a child in prostitution or any unlawful sexual activity; the exploitative use of a child in a pornographic performance and materials.” (WHO, 1999, p. 62).

The essential points are:

  • Sexual acts, direct or indirect, involving a person under the age of 16;
  • Child has inability to comprehend or understand the implication of the sexual act;
  • Compliance through coercion or manipulation; and
  • Involves a power imbalance with respect to:
    • Age.
    • Intellectual ability.
    • Knowledge/experience.
    • Status and authority.

Secrecy, misuse of power and the distortion of adult-child relationships are key factors in the sexual abuse of children. Whereas the term 'sexual assault' typically involves bodily contact, 'childhood sexual abuse' includes a wide range of behaviours, such as:

  • Touching, kissing, or holding a child in a sexual manner.
  • Sexualised communication, including making obscene phone calls or remarks to a child or young person.
  • Sending obscene emails or text messages to a child or young person, showing sexualised media (pornography), videos, photographs, printed material.
  • Persistent intrusion of a child's personal/private space, when undressing, washing.
  • Inviting a child to pose or perform in a sexual manner, to expose or touch them self.
  • Exposing a child to a sexual act, 'flashing', or exposing a sexual body part to a child.
  • Sexual assault, touching sexual organs, performing or receiving oral sex (with male or female), anal penetration.
  • Child sexual exploitation, prostitution.
  • Any unwanted, coerced, or consenting sexual activity before the age of consent.

Please also take a look at the Prevalence and characteristics module.

Common impacts

There is no prescribed way people are impacted on by sexual abuse or assault; everyone is different. However, we do know sexual abuse can have profound and long term effects on individuals' lives. This is not surprising when you consider that childhood is a time when assumptions about self, others, and the world are being formed, when safety, connection and sense of trust is paramount, when relations to our own internal states are being established, and when coping and interpersonal skills are being acquired.

People learn to cope and survive, in the best ways they can, in response to the abusive situation. While these ways of coping 'work' and often make sense in the immediate context of abuse, they can become problematic in and of themselves, and produce difficulties later on. Common difficulties men who have been sexually abused experience are:

  • Mental health difficulties such as depression, anxiety, suicidal ideation, dissociation, substance abuse, and self-harming behaviour.
  • Post-Traumatic stress disorder (PTSD) and complex PTSD, including sleep disturbances, flashbacks, hyper arousal, and avoidance behaviours.
  • Difficulties with interpersonal relationships and attachments, with intimate partner and sexual relations, lack of trust, sense of betrayal, withdrawal, and isolation.
  • Physical and neurobiological impacts such as pain, chronic hyper-arousal, and somatisation.
  • Impacts on meaning-making and sense of self, guilt, shame, self-blame.

(Banyard et al 2004. Tewkesburg 2007).

Please also take a look at the Effects module.

Gender analysis

The experience of being sexually abused sits within a cultural context where gender plays a significant role in shaping men’s health and well-being, their lives, and their relationships. Therefore, it is expected that program facilitators will possess a comprehensive gender analysis. A gender analysis is adopted in recognition that, in our society, gender influences who is subjected to sexual abuse and assault, where and in what ways; how sexual abuse is experienced; what are a person’s likely responses; ways of managing, subsequent impact on self, and a person’s help seeking behaviour; and the support available to them and what responses are effective (Briere & Scott 2006:78). A gender analysis acknowledges there are both similarities and differences in men’s and women’s experiences of sexual violence, and that there is a need to create responsive, evidence-based service provisions (including group programs) that recognise, but does not amplify these factors, given we know that:

“Many of the experiences of re-traumatization which adult survivors encounter with services are the result of misrecognition of their experience or needs, and both denial of the relevance of gender and exaggeration (through reliance on stereotypes).” (Hooper & Warwick, 2006, p.473)

When working with men who have sexually abused, it is important to remain aware of the multiple and contextual factors that impact on an individual’s mental health, relational, and physical well-being. Supporting change and enhancing well-being requires developing awareness of how personal experience and context, sexual abuse and gender, can intersect and shape men’s lives and developing a response that acknowledges these multiple influences.

Please also take a look at the Gender and sexual identity module.

Improved coping

It is understood that group facilitators will have a working knowledge of the developing research and practice evidence base of what contributes or not to men’s enhanced coping and well-being, and to use this to design and improve individual and group service responses. For example, it is now known that suppression, withdrawal, anger, denial, and acceptance (that 'this is my lot in life') are unhelpful long term coping strategies (O'Leary, 2009), whereas strategies correlated with men’s enhanced well-being are:

  • Accessing relevant, targeted information and support that assists in reducing sense of isolation and self-blame.
  • Practical assistance. Working to develop concrete life skills that address the impacts of sexual abuse, learning to tolerate emotional distress.
  • Talking with someone who is supportive: worker, partner, friend. (O'Leary & Gould, 2010).
  • Talking with someone who has encountered a similar event, and doing so in a context where men have the opportunity to offer support to each other (O'Leary & Gould 2010; Grossman, Sorsoli et al, 2006; Kia-Keating, Sorsoli et al., 2010).
  • Developing sense of hope, positive re-interpretation and growth, practicing optimism and self-understanding, viewing survival and life accomplishments in a positive manner. O'Leary and Gould, 2010; (Grossman, Cook, Kepkep, & Koenen, 1999; Wolin and Wolin, 1993).

Trauma Informed Care framework

Foundations is guided by the established three phase Trauma Informed Care framework. (Herman 2004; Courtois & Ford 2008, Courtois & Ford 2012, ASCA 2012). It is understood that practitioners will have an established working knowledge of the trauma informed care framework, and have integrated this framework within their individual, group work, and organisational practice.

Key principles of trauma-informed care include safety, trustworthiness, choice, collaboration and empowerment. A Trauma Informed Care Practice (TICP) framework recognises the impact of power differentials in service settings, maximises self-determination, supports autonomy and empowers individuals to learn about the nature of their injuries and to take responsibility in their own recovery. Non trauma-informed services often mirror the power and control experienced in the abusive relationships that caused the past trauma making recovery difficult and the risk of re-traumatisation real... TICP is informed by an understanding of the particular vulnerabilities and 'triggers' that survivors of complex trauma experience, with services delivering better outcomes, minimising re-victimisation and ensuring that self and community wellness and connectedness can be promoted.” (Bateman, Henderson and Kezelman 2013: 9).

The Trauma Informed Care framework emphasises and builds on the following three phases.

Phase 1: Safety, stabilisation, and engagement

  • Emphasis on engaging and developing a working alliance with individual participants and the group as a whole.
  • Enhancing sense of self and relational capacities. While many men experience social isolation, the group experience can expand what in many cases is their minimal social support network.
  • Developing knowledge and understanding of the impacts of trauma.
  • Expanding repertoire of strategies for managing overwhelming thoughts (memories) and emotions (ensuring access to basic material resources, secure accommodation, food).
  • Developing tools and strategies for approaching and mastering internal bodily/affective states and external events that trigger intrusive re-experiencing, emotional numbing, or disassociation (Courtois & Ford 2009).

The Foundations group program emphasises this first phase of safety, stabilisation, and engagement. Safety is fundamentally important to a functioning and supportive group. Given that this may be the first focused therapeutic work for some participants, there is a need for facilitators to actively support structured, safe engagement.

Possibly because initial work on establishing a 'secure base' involves limited discussion of traumatic events, some facilitators and participants can believe this work is peripheral to the 'real work'. Some participants may want to 'fast forward' to 'telling' and processing, working under the belief that this telling will in and of itself provide relief. As will be discussed, the trauma-informed facilitator must be prepared to step in to ensure discussions are safe for all, that they do not involve rushed disclosures that produce regret and amplify shame, or support excessive focus on physical detail that can be triggering. The Jacaranda Project Groupwork Manual (2011) emphasises 'Safety' as 'The Essential Component of Best Practice'.

“From the results of the Jacaranda Project research and through our involvement, we have learnt a great deal about the power and effectiveness of group work as an intervention for adult survivors of child sexual assault. However, therapeutic as it ultimately is, participating in a group is also triggering and unsettling. There is a danger of re-traumatisation as the participants are facing the reality of their own abuse, and exposed to others' stories of abuse. What that tells us is that that we have to be highly conscious of ensuring safety. There needs to be constant attention to the creation and maintenance of a contained and containing environment for group members.” (Jacaranada Project 2011:7).

Phase 2: Processing and meaning making for self

  • Focus on cognitively and emotionally processing the experience of sexual abuse.
  • Meaning making for self in the present.
  • Examining questions of responsibility, shame, guilt, grief, and loss, and addressing self blame.
  • Support in developing a coherent autobiographical narrative.
  • Maintenance of established life style and relationships (Courtois & Ford 2009).

Phase 2 involves supporting group members to develop the tools and understanding to safely look again, as adults, at what was done, in a way that acknowledges the context of the past in the present. It involves reviewing and unpacking complex, long held interpretations of events, and an opportunity to examine questions of responsibility and the influence of silence, secrecy, guilt, shame, and self blame. Individual emotional processing of sexual abuse is not a feature of the initial Foundations group. It is suggested that emotional process of past trauma is ideally primarily undertaken as a planned structured activity within individual counselling. In Foundations, there is an emphasis on supporting participants' meaning making, and developing a coherent personal narrative that accepts the presence of gaps in memory and knowledge.

It is useful to note that phase two of the trauma informed framework, when working with survivors of childhood sexual abuse, is slightly different from phase two 'Remembrance and Mourning' of the framework as articulated by Herman (2004). For many people sexually abused in childhood, the processing and meaning making goes beyond remembrance and mourning, as the abuse occurred at a time when the sense of self was becoming established, and for many there is no established sense of self separate from, or life 'before', the sexual abuse.

Phase 3: Developing sense of personal and relational integrity and well-being

  • Enhancing emotional literacy and emotionally engaged living.
  • Building connection with self and others.
  • Addressing injustice, and relational impacts of abuse.
  • Developing range of trusting, respectful, caring relationships (partner, parent, friend).
  • Nurturing. Closeness and intimacy and satisfying sexual life.
  • Possessing a clearly articulated sense of self, with purpose (Courtois and Ford 2009).

In recognition of the profound impact that sexual abuse can have on sense of self and interpersonal relationships, Foundations places an emphasis on developing personal and relational integrity. This may be a participant's first opportunity to reflect upon, consider, and establish a sense of self, of who he is and what he stands for, that is not overshadowed by the legacy of sexual abuse. This is an opportunity for a community of men to name and confront the injustice of sexual abuse and its relational impacts, and to build the foundational stepping stones towards connection and well-being.

Just like Phase 1, Phase 3 is a critical area of individual and group work. It is about supporting participants to engage in committed action, in order to live a valued life according to their own identified purpose and preferences. He may choose to take time to build his mind-body connection, to befriend his body (e.g., yoga, meditation), deepen his relationships with others (i.e., as partner, as father) and to be more engaged in community. He may choose to join other participants in building peer and community support networks, to develop awareness and understanding of sexual abuse and its impacts. This is where participants step away from being defined by the past, towards engaging in transformative action where the locus of control is with them in creating a preferred future.

The value of group work

The value of developing and facilitating groups specifically to assist men who have been sexually abused in childhood has been recognised since the 1980s (See Bruckner & Johnson, 1987; Wilkien 1989; Crowder 1993; Friedman, 1994; Lew, 2004; Fisher, Goodwin, & Patton 2008; O'Leary, 2009; Singer, 2009; O'Leary & Gould, 2010; Hopton & Huta, 2012).

Amongst the profound impacts that men subjected to child sexual abuse can experience are overwhelming feelings of isolation, of being alone, a sense of personal failure, and being somehow different from all other men. Group work plays a particularly powerful therapeutic role in addressing these impacts for men, and in enhancing their personal and relational well-being.

A primary value of men's group programming is its ability to address the silence, isolation, and shame that men who have been sexually abused often experience throughout their lives. Group work helps to 'normalise' experiences, in a way that individual counselling cannot. It provides men with an opportunity to meet and talk with men who have had similar experiences, who face common difficulties, to share knowledge and understanding, whilst being supported by professionally trained facilitators. While children and adults experience abuse through boundary violation with others, it is through engagement in respectful, supportive, interpersonal relationships that such violation and betrayal of trust can be addressed.

Participation in groups involves engagement at a physical, emotional, intellectual, and experiential level. Group work is based on the premise that people come to understand and make sense of themselves through interactions, and their relationships with each other. In essence, group work is an opportunity not only to work in community, but to re-work one's capacity to connect and be in community. This includes the opportunity to consciously practice new ways of relating to and being with others, which involves an inherent level of risk taking by participants.

Through group participation and engagement, members of trauma-based programming share their strengths, bringing awareness to 'what people have learned about themselves, others, their world as they have struggled, coped with, and battled abuse, trauma, illness, confusion, oppression, and even their own fallibility' (Saleebey, 2008).

The value of both individual counselling and group support

A combination of individual and group support is now identified as the 'gold standard' in assisting adults to address childhood trauma (Cloitre, Courtois, Charuvastra, Carapezza and Stolbach 2011:622). To recommend and present the value of developing a group program for men who have been sexually abused is not to privilege it over individual counselling. Trauma informed therapeutic group work can act as a valuable addition to individual counselling. In highlighting the value of group work, it is important to recognise that, for some male survivors, the thought of joining a men's group can be overwhelming and beyond comprehension. Whilst some men will 'never' join a group, for others the initial sense of safety and containment provided by individual counselling can act as a valuable bridge towards joining a group, and for others it is only after participating in a group program that they see value in individual counselling. Ideally, individual counselling and group support complement each other. Each has a role to play, as Parker (1990) observes, 'What individual work provides in depth and particulars, group work provides in breadth and enhanced power' (cited in Gartner, 1999: 295).

Group diversity

Foundations serves men, 18 years or over, who have been sexually abused in childhood. Experience has shown that including men from a mix of diverse backgrounds and experiences can add value to the group.

While Foundations is designed to serve all men, there are populations of men that can benefit from dedicated groups in order to properly serve their needs. Including:

  • Aboriginal and Torres Strait Islander men (First Nation Métis/Inuit men).
  • Men from culturally and linguistically diverse communities.
  • Incarcerated men.
  • Men with intellectual and learning difficulties.
  • Same sex attracted and Gay Identifying Men (typically Foundations groups will contain one or two Gay Identifying Men, however there may be a community interest/benefit in designing a specific group).

In order to better serve the above populations, facilitators will need to consult, revise, add to, and adapt programming to create an engaging and more meaningful, relevant and effective program. Creating revised and adapted programs provide a valuable opportunity to improve service delivery, knowledge and skill, and to collaborate, share resources, and learning with other services.

Summary

In summary, Foundations is formed and based on the understanding that, while childhood sexual abuse can have a profound impact on men’s lives, the focus of work with men reaches beyond one of symptom management, and towards understanding their lives and struggles in context, including all diversities, to enhance overall quality of life. This more expansive focus on personal, relational, and community well-being is consistent with a belief that:

“Recovery and resilience do not reflect simply the absence of problematic symptoms, but rather a zest for life; a positive conceptualisation of one’s self; the ability to form positive, supportive, and safe relationships; and the ability to achieve a fulfilling quality of life.” (McMackin, Newman, Fogler & Keane, 2012).

 

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Last modified: Sunday, 15 October 2017, 3:29 PM