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Chapter Five: Wider Issues in Support Planning

This booklet concentrates on the initial and early stages of work with survivors of sexual abuse. It also focuses on basic principles of working in one-to-one situations with survivors: how can their underlying problems be better identified? How can you become more confident to ask tactful questions and offer support? How can the working environment and personal approach help survivors talk safely and freely about abuse issues? We have, so far, concentrated on ways of building and maintaining the one-to-one relationship because that is such an essential part of achieving those aims.

But, of course, this does not imply that continuing one-to-one work involving the survivor and one support person, or support agency, is the only, or necessarily the best, way of working with that survivor. Nor does it imply that any particular counselling, therapeutic, or 'talking treatment' approach, is superior to any other means of giving support, achieving change or tackling sexual abuse.

Talking with, and listening to survivors, makes us aware how varied their problems can be, how these problems are often practical as well as emotional, how many different agencies may have valuable assistance to offer, and how important it can be to consider help that may be needed for their wider family and social networks. Working with the 'whole person' means taking into account all aspects of their lives that may have been touched by the effects of the abuse, including their family and social relationships, their education and work, their health, and a range of possibly unaddressed concerns - for instance their concern for justice for themselves, and for other adults and children who have suffered abuse.

Consultation with survivors always helps support plans

"Nobody ever asked me what I wanted."

(Client who spent more than 15 years in and out of psychiatric care)

One clear lesson that emerged from the Beyond Trauma study was that, apart from one extremely distressed and damaged teenager, every woman interviewed, despite her mental distress, was able to describe clearly the main problems the abuse had caused for her, or her children, which she wanted to be addressed. Most of the women had rarely been asked this question before, and some never. The examples below show just how diverse the problems they identified were. They include major issues, such as justice and protection. Their responses offered many pointers to the (often practical) assistance women needed. Their examples also demonstrate to workers reading this booklet that, when survivors are consulted, it becomes much easier to see which agencies might be helpful to them and to other important people in their lives. Examples included:

• Legal advice for the survivors, or their children, especially on taking cases to court.
• Stronger action by police and social workers to protect known children, whom the survivors believed to be at risk.
• Help to access medical and social work records, which would piece together distressing, confusing "memory blanks" about their childhood.
• Help to find accommodation which was safe, secure and confidential.
• Counselling focussed on their feelings of bereavement and loss about teenage miscarriages and forced abortions.
• Agency mediation, or advice, to repair fractured relationships with their adult siblings, their mothers, their partners or their own children.
• Practical and emotional support for their (non-abusing) partners.
• Specific treatment to reduce intrusive thoughts and the 'voice in the head' of the abuser.
• Conventional, alternative or complementary therapies for debilitating physical health problems.
• Help with literacy problems caused by emotional 'blocking' in their childhood, which hampered efforts at learning, work or training.
• 24-hour survivors' helpline to cope with frequent suicidal feelings.
• Specific help to reduce overwhelming fears of leaving young children with any babysitter, crèche or nursery.
• Practical childcare support for mothers, including accessible, safe childcare projects in their own communities, when they were suffering depression and could not fulfil their usual responsibilities to their children.

Consulting people in this way by asking, "What problems do you think the abuse is still causing for you now?" "What issues would you like help with now?" does not stop professionals using their own skills and judgment as part of that assessment. But it does mean survivors' own judgments and views need to be an essential part of support planning - including multi-agency planning - for both the present and the future.

The cost of ignoring the survivor

Overlooking this can at best be futile, and at worst can have serious consequences for the survivor and his/her family. For instance, elaborate multi-agency plans involving social work, addiction agencies, children's reporters and psychiatric services may be drawn up for a mentally distressed, substance-abusing woman and her children. If these fail to understand, or address, underlying abuse issues, or the woman's priority needs, these can simply prove a waste of time and money.

One example from the Beyond Trauma research concerned a mother who was viewed very negatively by a range of statutory agencies, whose children went in and out of care, and for whom many (largely unsuccessful) multi-agency plans had been attempted. She eventually managed to tell the research interviewers the reason why she rejected her son: her own brother had started abusing her at her son's age. She felt continually terrified for the safety of her young daughter. Sympathetic listening and talking about the abuse issues might have drawn this information out sooner, and relevant strategies might have been developed to address what had become a very damaging problem for her children and herself.

Services which should consider checking routinely for a CSA history

Sometimes, the need to consider abuse issues in planning for people's needs and addressing their problems is especially urgent. We believe that the managers, directors and commissioners of services should seriously consider the stage when this ought to become a point of policy. In certain services, where a history of abuse may be having a strong influence on desperate, dangerous, very distressed or chaotic behaviour, and where unaddressed abuse may result in further risk to self or others, we believe that exploring for a possible history of sexual abuse should be included in the routine assessment process. At present this does not happen often enough. It need not take the form of a blunt question, nor need it take place at immediate contact by the client with the service: it can be a tactful exploration of the issue over the early phases of a person's contact with services.

The reason why this is a topic for managers, directors and commissioners is that, as with support and supervision issues (see chapter 4), they alone may be in a position to create and enforce changes in practice.

We suggest that the routine exploration of an abuse history should be considered as a priority in services dealing with:

• Acute psychiatric admissions
• Chronic mental distress and 'treatment-resistant' mental illnesses
• Personality disorders
• Forensic psychiatry and work in Special Hospitals
• Attempted suicide
• Persistent self-harm
• Heavy substance misuse
• Serious and persistent offending
• Homelessness
• People with several unexplained, chronic physical health problems
• All services dealing with disturbed behaviour (including eating disorders) in young people under 18, where there may also be important child protection issues involved.

SUMMARY OF KEY POINTS

• Child sexual abuse takes many forms, and has a wide range of effects.
• Not all survivors will be suffering and in pain - many do manage to turn their distress into personal strengths, and live happy and successful lives.
• However, many survivors face serious physical or mental distress.
  It is not helpful to assume that they are somehow 'all right' if we ignore the issue, or that addressing the issue will make them 'worse'.
• Currently, many workers across a range of services fail to see, or ask about, the underlying cause of the distress, only dealing with the symptoms.
• Many factors can hinder survivors who want to talk about their sexual abuse. These include individual factors such as fear, stigma and embarrassment, as well as external factors, such as workers not picking up on cues or hints, not believing survivors' stories, believing that they need special training, believing that it would do more harm than good to speak about the abuse, and feeling embarrassed or uncomfortable. Lengthy training is not necessary for dealing with initial disclosures, since this is about the role of empathic listener. It is required, however, for working with moderate to severe mental health problems associated with sexual abuse, such as dissociation, Post Traumatic Stress flashbacks, 'personality disorder' diagnoses, psychotic episodes.
• Talking about sexual abuse, like talking about suicide, DOES NOT make things worse - it is an essential step on the road to healing. It is important though, to try to ensure that the service user has support outside the service, as survivors may experience a worsening of distress symptoms in the short term.
• You CAN help survivors by making opportunities for people in distress to disclose sexual abuse where this has happened to them. It might be part of your routine assessment procedure or could be mentioned sensitively, such as asking, "Did anyone hurt you when you were a child?"
• Remember that while some survivors may need years of intensive support, others may have much more defined and limited needs.
• When you are discussing sexual abuse with survivors, including longer-term support planning, always ask how they see their own needs, and what would be helpful for them.
• Basic human skills and characteristics, such as empathy, trust, understanding and respect, are the most important qualities in working with survivors.
• Be flexible in approach but secure about boundaries. Keep to agreed meetings, don't overstep your personal limits, be consistent.
• Supervision and structured support is essential for any intensive, continuing or longer-term work with survivors, and also if you have been distressed through hearing painful details. If you are a manager, you have a responsibility to make sure your staff or volunteers are adequately supported.
• DON'T pass survivors from pillar to post. View other professionals and specialist sexual abuse agencies as additional supports for the survivor, but don't feel you have to withdraw your own support.

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