Childhood Trauma Therapy: CFTSI Model by Hanlie Wentzel

Childhood Trauma Therapy 1. Contact & Contract: Healing Pathway 2. Assessment of Trauma: Assessment Tools 3. Intervention: CFTSI Model Psycho Education & Skill Building Emotional Healing Art Therapy: Narrative Therapy 4. Terminate Therapy 5. Follow up Assessment

Hanlie Wentzel 079 877 8678 Baobab Consulting hanlie.baobab@gmail.com www.baobabtherapy.co.za

CFTSI THERAPEUTIC MODEL FOR CHILD TRAUMA COUNSELING TREATMENT (Child Family Traumatic Stess Intervention Treatment) Trauma from child abuse can produce devastating effects on children, making them afraid, anxious, depressed, and unable to stop thinking about the abuse. It can also harm their ability to perform well in school and to relate well with others. Trauma can also lead to problems as children get older, unable to fully function as adults, or developing substance and alcoholic abuse issues to numb their pain. These reasons are why the Yale University School of Medicine’s Child Study Center developed the Child Family Traumatic Stress Intervention treatment, known as CFTSI. Working in partnership with Safe Horizon’s Child Advocacy Centers for the past four years, Yale University has been able to adapt Child Family Traumatic Stress Intervention treatment with child victims and their caregivers at Safe Horizon’s Child Advocacy Centers. Through CFTSI, children are brought together with their parents or caregivers so the whole family can learn how to recognize and deal with trauma symptoms. What makes CFTSI treatment special is its emphasis

on engaging the entire family to help children

heal from abuse. CFTSI counselors works with parents of children ages seven to 18, to identify their child’s trauma symptoms, learn how to discern them, and learn practical skills to help deal with trauma symptoms. CFTSI treatment takes place over the course of just four to six sessions. This shorter treatment period helps families who may not feel ready to commit to longer-term treatments, who have multiple issues to deal with in the aftermath of abuse, or who may not need longer-term treatment. The results from the treatment have been remarkable. When Yale initially studied the results of treatment for children and families in their pilot program on the Yale campus, they found 73% of those children were less likely than children and families undergoing other counseling methods to show some or all symptoms of trauma. Working with families through our Child Advocacy Centers, the reductions in trauma symptoms have been quite remarkable as well – results that Dr. Carla Stover from Yale has described as “not only a statistically significant reduction, but a clinically significant one as well.” With CFTSI treatment, children, their parents and their siblings feel better, and the healing process can begin. The Child and Family Traumatic Stress Intervention (CFTSI) is a brief intervention designed to decrease the negative impact of children’s exposure to potentially traumatic events (PTE). The primary goal of the CFTSI is to prevent a child from developing posttraumatic symptoms and disorders by increasing the child and family’s ability to communicate feelings and thoughts effectively and to then enhance parental emotional and behavioral support after a PTE. The secondary goal is to increase the rate of children that enter the appropriate treatment if their symptoms and difficulties do not diminish sufficiently, develop or concretize sometime later. An additional and related goal has to do with the frequent experience of seeing a child due to a recent PTE and learning that the child has experienced one or prior PTE’s or has lived with chronic stress and adversity. When this is the case, it feels as if a brief treatment such as the CFTSI is insufficient to address the enormity of psychosocial issues faced by the child and their family. Although, it is likely that the CFTSI is not entirely enough to address the child’s difficulties, it may be an optimal beginning in which notions of psychotherapy and the importance of parental supervision, attention and support can lay the groundwork for future treatment. Many families and children are unable or unable or unwilling to commit to longer treatments from outset, but are willing to engage in a brief treatment. It is hoped that a positive experience with the CFTSI will be an encouragement for families to seek additional needed treatment.

The CFTSI should be implemented soon after a PTE (within 1-2 weeks post event, maximum) and is a 3 to 4-session intervention that can be provided in the family home or clinician’s office. A unique aspect of the CFTSI is that measures that have been used routinely in research and diagnostic protocols for children have been adapted to be used throughout the intervention and serve as clinical tools. These tools provide a reliable method to expeditiously ascertain, the status and current functioning of the child and family, and are employed in each session as evaluation and monitoring instruments as well as a focus for discussion. In other words, while they are recognizable research and diagnostic measures, they are used strictly for clinical purposes during the intervention.. The clinical tools include adaptations of the PTSD-RI and Mood and Feelings Questionnaire, The Parent Behavior Inventory and the Social Support-Family Instrument. Since the CFTSI involves a great deal of reporting on symptoms and feelings, it is best for children 7 years old and up. Younger siblings may benefit from participation, when they too have been exposed, but they are unlikely to be able to respond to interview questions in a effective manner. Most of the research literature agrees that social and family supports are some of the most salient protective factors in preventing negative outcomes for individuals after exposure to PTE . The CFTSI attempts to increase the ability of a family, especially parents, to support their child in a number of ways. 1. 2. 3.

Increase the child and parental understanding of the possible impact of exposure to PTE on symptom formation, behavioral changes and daily functioning (psycho education). Increase the child’s ability to communicate feelings and symptoms to parents. Increase parent’s ability to respond appropriately and supportively to the child’s difficulties, by teaching them certain strategies and interventions to do with their child and reminding themselves and their child about the correlation between behavioral changes, internal feeling states and the PTE.

It is hypothesized that by instructing the child and family in these three areas, children will feel more supported, which will lead to improved post exposure outcomes.

Program Description Program Goals Child and Family Traumatic Stress Intervention (CFTSI) is an early intervention and secondary prevention model that aims to reduce traumatic stress reactions and posttraumatic stress disorder (PTSD). It is delivered to children aged 7–18 years, together with their parent or caregiver, after the child has experienced a potentially traumatic event (PTE). Examples of PTEs are events such as sexual and physical abuse, domestic violence, community violence, rape, assault, and motor vehicle accidents. Children are referred by law enforcement, child protective services, pediatric emergency rooms, mental health providers, forensic settings, and schools.

Program Activities SESSION 1: In the first session, treatment providers meet with the parent or caregiver alone. The process is explained step-bystep and its intervention, rationalized. Providers use a psycho–educational approach when explaining typical reactions to PTEs and the importance of familial support. A series of questionnaires are completed in order to assess the parent or caregiver’s psychological status throughout the intervention. During this session, providers discuss external stressors related to the PTE, and a case management plan is set up.

SESSION 2: The second session occurs as close to the first session as possible and includes the provider, child, and parent or caregiver. The first half of this session starts with just the provider working with the child. This is followed by the provider, child, and parent or caregiver together. The second half of this session lays the groundwork for future aspects of the intervention. A series of questionnaires, similar to those given to the parent or caregiver during session 1, are also completed by the child. Then answers from both participants are compared. Areas of agreement are praised and areas of disagreement are seen as opportunities to improve communication by helping the child learn how to better inform the parent or caregiver about their symptoms and helping the parent or caregiver be more aware, receptive, and supportive of the child.

It is for Freedom that Christ has set us free

Providers end the session by providing the child and parent or caregiver with behavioral skill modules to work on as homework before the next session. These areas include sleep disturbance, depressive withdrawal, tantrums, intrusive thoughts, anxiety, and techniques to manage traumatic stress symptoms.

SESSION3: The third session includes all three participants, where the child completes questionnaires, with the parent or caregiver providing perspective on the items mentioned. The main emphasis is adjustment of communication efforts to improve the effectiveness of behavioral skill modules as well as other supportive measures. The final session is delivered almost identically as the third, with the end of this session focused on future check-ins and possible plans for more extensive treatments.

The Child and Family Traumatic Stress Intervention (CFTSI) is a Family strengthening intervention. Intended for children 7 to 18 years old who have either recently experienced or disclosed traumatic events. That aims to: 1. Reduce early post-traumatic stress symptoms; 2. Decrease the likelihood of traumatized children developing long-term post-traumatic psychiatric disorders; and 3. Identify children who need longer-term mental health care.

CFTSI description Session 1 Caregiver Alone

Session 2 Child Alone

Session 3 Child Alone

• Explanation of process; intervention rationale; psychoeducation • PCL for caregiver • Review case management needs • HPI, developmental • History, family history, etc. • Administer questionnaires as clinical interviews: PTSD-RI, MFQ

• Explanation of process; Intervention rationale • Administration of PTSD-RI and MFQ • Provide psychoeducation about how child’s symptoms are related to the PTE • Provide support, normalize symptomatic reactions • Teach relaxation techniques to address symptoms: diaphragmatic breathing, etc.

• Review symptoms to assess changes • Review psychoeducation • Provide support, normalize symptoms and feelings • Practice relaxation techniques • Review coping strategies based on symptoms (e.g., guided imagery, thought stopping, distraction techniques)

Session 4 Caregiver and Child • Administer PTSD-RI and MFQ • Feedback re: child’s status • Discuss disposition

Session 1 Only the adult caregivers and the provider are present for the first session. At its opening, the clinician explains each step in the process and its rationale. A psychoeducational approach is applied with explanations of typical reactions to PTEs and the protective role of family support. Consistent with the focus on the essential role of caregivers, the  Posttraumatic Checklist–Civilian version (Weathers, BLitz, Huska, & Keane, 1994) is administered. This allows the clinician to integrate an understanding of the caregiver’s psychological status throughout the intervention. External stressors related to the recent PTE are identified and a plan for managing them is developed. We have found that addressing eventrelated stressors both serves as an engagement tool and permits caregivers to more readily focus on the child’s emotional needs.  Lastly, the caregivers are administered parent versions of the Trauma History Questionnaire (THQ; Berkowitz & Stover, 2005),

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and modified versions of the UCLA Posttraumatic Reaction Index (PTSD-RI; Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998) and the Mood and Feelings Questionnaire (MFQ; Angold & Costello, 1987), which will be the central focus of the joint session to follow.

Session one and all subsequent sessions average one to one and one half hours in length.

Session 2 Session Two occurs as close to Session One as possible and the provider meets first with the child alone and then with caregivers and child. The second half of this session is the core component of the CFTSI and lays the groundwork for all subsequent aspects of the intervention. First, the child is administered the THQ, PTSD-RI and Short MFQ. The clinician, with the child and caregiver/s, facilitates a comparison of the responses as means of improving communication, which is the presumed prerequisite to enhancing caregiver emotional support. If there is an agreement about symptom severity the parent and child are praised. Discordance is seen as an opportunity to increase communication. The clinician takes a dual approach to improving communication, helping both the child to better inform the parent about symptoms, and the parent to be more aware, receptive, and supportive. Session Two ends with the clinician proposing two areas of concern based on symptom clusters which the child and caregivers have identified as most problematic. Together the clinician and family choose one to two behavioral skill modules as ‘homework’ before the next session. These modules cover 6 topic areas (1) sleep disturbance, (2) depressive withdrawal, (3) oppositionality/tantrums, (4) intrusive thoughts, (5) anxiety, avoidance and phobic reactions, and (6) a general overview of traumatic stress symptoms and techniques to manage them. Each module reviews psychoeducation and specific techniques, with separate instructions for the caregiver and child to discuss and practice. The maintenance of routines is emphasized throughout. Specific techniques involve both behavioral and cognitive procedures such as thought replacement methods for intrusive thoughts, breathing retraining for anxiety, behavioral activation for depression and avoidance. The specific elements for addressing each problem area have been borrowed and adapted from well-accepted methods from the traumatic stress treatment literature.

Session 3 The caregivers, child, and clinician meet together for Session Three; demonstrating the solution to the child’s difficulties is a family matter. The same symptom surveys are administered with the child responding first and the caregivers offering their perspective on the items. It permits symptom monitoring as well as an examination of which methods of communication and supportive efforts were most successful. Efforts center on adjustments to improve communication efforts and review the effectiveness of the skill modules and other supportive measures. While the skill modules were reviewed during Session Two, they are practiced in Sessions Three and Four.

Session 4 Session Four essentially duplicates Session Three, with one key difference. The end of the session is used to discuss next steps. Depending on the status of the child, the clinician may suggest a future check-in, evaluation and treatment for an apparent preexisting psychiatric disorder or a more extensive treatment for PTSD.

ASSESSMENT TOOLS APPENDIX A: Baseline Visit and Demographic Information Complete the following. 1. Date of visit: ___ ___ ___ / ___ ___ / ___ ___ ___ ___ Month Day Year

Baseline Visit Information 2. Is this the child’s first visit at this center for the current episode of care?  No, If No: How many visits (including today’s visit) has the child had at your center for the current episode of care? Number of Visits _____  Yes 3. From whom are you collecting information for this form? (Check all that apply)  Parent  Other adult relative  Foster parent  Agency staff  Child/adolescent/self  Other, Specify: 4. Who is currently the legal guardian for this child? (Check only one)  Parent  Other adult relative  Social Services  Emancipated minor (self)  Other, Specify:  Unknown

Demographic Information 5. Child’s ethnicity (Check only one):  White  Coloured  African  Other/Unknown 6. Child’s race (If multiracial, check all that apply): 7. Was the child born in South Africa? 0 No� If No: In what country was the child born? 1 Yes 99 Unknown 8. Is the child (and/or family) a refugee, asylum seeker, or immigrant with a history of exposure to community violence?  No  Yes  Unknown

Core Clinical Characteristics (Baseline Assessment Form)d Demographic Information () 9. Is this child currently participating in other therapy or intervention?  Unknown  No  Yes � If Yes, specify: ______________________ Please provide visit date(s) the interventions were administered. Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Intervention by: _______________ Month Day Year Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Intervention by: _______________ Month Day Year Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Intervention by: _______________ Month Day Year 10. Please provide an identifier for the health care provider currently caring for this child______________________

Brief Intervention Services Information Brief Intervention refers to the number of sessions that a child/family may receive. If a child/family is receiving 3 – 6 sessions, then complete the following. Is this child/family receiving brief intervention services?  No  Yes 1. What treatment component(s) is the child/family receiving for this brief episode of care? (Check all that apply)  Screening  Psycho-education  Assessment  Safety Planning  Case Consultation  Individual Therapy  Case Management  Family Therapy  Child and Family Traumatic Stress  Group Therapy Intervention (CFTSI)  Support Group  Crisis Management  Other, Specify:  Referral Services 2. Date this brief episode of care began: __/__/_____ NOTE: Answer question 3 after the child/family has completed the selected treatment component(s). 3. Did this child/family complete the treatment component(s) offered during this brief episode of care? 1 No, left treatment before completing � If No: Date left treatment: __/__/___ 1 Yes, completed treatment � If Yes: Date completed treatment: __/__/____

Domestic Environment Where is the child’s current primary residence? (Check only one)  Independent (alone or with peers)  Homeless  Regular foster care  With relatives or other family  Correctional facility  Residential treatment center  Home (With parent(s))  Unknown  Place of Safety How many months has the child been living in above setting? _____(Enter number of months or “0” if less than one month) OR Entire life OR Unknown

Domestic Environment Details If ‘Home with parent(s) or ‘With relatives or other family’ is selected for primary residence on the Insurance Information and Domestic Environment form at Baseline complete the following questions. 1. What types of adults live in the home with the child? (Check all that apply)  Mother (Biological or adopted)  Other adult relative  Father (Biological or adopted)  Other adult non-relative  Parent’s partner/significant other  Unknown  Grandparent  Other, Specify: 2. Total number of adults (18 years of age or older) living in child’s home: OR Unknown 3. Total number of children younger than 18 years of age (including client) living in child’s home: _______ OR Unknown 4. Please specify zip code of child’s current residence: __ __ __ __ __ (5 digit zip code) OR Unknown 5. Primary language spoken at home: (Check only one)  English  Afrikaans  African language, specify: ___________________  Other, specify: ____________________ 6. What is the total income for the child’s household for the past year, before taxes and including all sources:

Services Received BASELINE INSTRUCTIONS: Has the child received any of these services or been placed in any of the following (excluding today’s visit) within the past month (within the past 30 days). These may include services provided by your Center as well as services provided by any other clinician, setting or sector.

1. Inpatient psychiatric unit or a hospital for mental health problems 0 No 1 Yes 99 Unknown 2. Residential treatment center (A self-contained treatment facility where the child lives and goes to school) 0 No 1 Yes 99 Unknown 3. Detention center, training school, jail, or prison 0 No 1 Yes 99 Unknown 4. Group home (A group residence in a community setting) 0 No 1 Yes 99 Unknown 5. Treatment foster care (Placement with foster parents who receive special training and supervision to help children with problems) 0 No 1 Yes 99 Unknown 6. Probation officer or court counselor 0 No 1 Yes 99 Unknown 7. Day treatment program (A day program that includes a focus on therapy and may also provide education while the child is there) 0 No 1 Yes 99 Unknown 8. Case management or care coordination (Someone who helps the child get the kinds of services he/she needs) 0 No 1 Yes 99 Unknown 9. In-home counseling (Services, therapy, or treatment provided in the childâ&#x20AC;&#x2122;s home) 0 No 1 Yes 99 Unknown 10. Outpatient therapy (From psychologist, social worker, therapist, or other counselor) 0 No 1 Yes 99 Unknown 11. Outpatient treatment from a psychiatrist 0 No 1 Yes 99 Unknown 12. Primary care physician/pediatrician for symptoms related to trauma or emotional/behavioral problems. (Excluding emergency room) 0 No 1 Yes 99 Unknown 13. School counselor, school psychologist, or school social worker (For behavioral or emotional problems) 0 No 1 Yes 99 Unknown 14. Special class or special school (For all or part of the day) 0 No 1 Yes 99 Unknown 15. Child Welfare or Department of Social Services (Include any types of contact) 0 No 1 Yes 99 Unknown 16. Foster care (Placement in kinship or non-relative foster care) 0 No 1 Yes 99 Unknown 17. Therapeutic recreation services or mentor 0 No 1 Yes 99 Unknownervices Received (continued) 18. Hospital emergency room (For problems related to trauma or emotional or behavioral problems) 0 No 19. Yes 99 Unknown 19. Self-help groups (e.g., AA, NA) 0 No 1 Yes 99 Unknown

Clinical Evaluation Based on your clinical evaluation, for questions 1-21 please check each problem/symptom/disorder currently displayed by the child. For question 22 please indicate the primary problems/symptom/disorder currently displayed by the child. Clinical Problems, Symptoms, & Disorders Child has/exhibits this problem? (Answer all that apply) 1. Acute stress disorder 0 No 1 Probable 2 Definite 2. Post traumatic stress disorder 0 No 1 Probable 2 Definite 3. Traumatic/complicated grief 0 No 1 Probable 2 Definite 4. Dissociation 0 No 1 Probable 2 Definite 5. Somatization 0 No 1 Probable 2 Definite 6. Generalized anxiety 0 No 1 Probable 2 Definite 7. Separation disorder 0 No 1 Probable 2 Definite 8. Panic disorder 0 No 1 Probable 2 Definite 9. Phobic disorder 0 No 1 Probable 2 Definite 10. Obsessive compulsive disorder 0 No 1 Probable 2 Definite 11. Depression 0 No 1 Probable 2 Definite 12. Attachment problems 0 No 1 Probable 2 Definite 13. Sexual behavioral problems 0 No 1 Probable 2 Definite 14. Oppositional defiant disorder 0 No 1 Probable 2 Definite 15. Conduct disorder 0 No 1 Probable 2 Definite 16. General behavioral problems 0 No 1 Probable 2 Definite 17. Attention deficit hyperactivity disorder 0 No 1 Probable 2 Definite 18. Suicidality 0 No 1 Probable 2 Definite 19. Substance abuse 0 No 1 Probable 2 Definite 20. Sleep disorder 0 No 1 Probable 2 Definite 21. Are there any other additional problems currently displayed by this child? Specify: _____________

General Trauma Information Primary focus of current treatment? (Select only one) 1 Sexual maltreatment/abuse 2 Sexual assault/ rape 3 Physical maltreatment/abuse 4 Physical assault 5 Emotional abuse/Psychological Maltreatment 6 Neglect 7 Domestic Violence 8 War/Terrorism/Political violence inside the U.S.

9 War/Terrorism /Political violence outside the U.S 10 Illness/Medical Trauma 11 Serious injury/Accident 12 Natural Disaster 13 Kidnapping 14 Traumatic loss or bereavement 15 Forced Displacement 16 Impaired Caregiver

17 Extreme interpersonal violence (not reported elsewhere) 18 Community Violence (not reported elsewhere) 19 School Violence (not reported elsewhere) 20 Other Trauma (not reported elsewhere)

Maltreatment/Abuse

APPENDIX B: TRAUMA DETAILED ASSESSMENT 

Trauma Detail, Sexual assault/ Rape

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Unrelated (but identifiable) adult (Check only one)  Sibling  One-time event  Other youth  Repeated exposure  Stranger  Unknown  Unknown 3. Please describe the type(s) of experience. (Check 6. Was serious injury inflicted? 0 No 1 Yes� If YES, to all that apply) whom:  Experienced  Child (Check all that apply)  Witnessed  Parent  Vicarious  Unknown  Unknown  Other adult relative 4. Please indicate the setting(s) of the experience.  Unrelated (but identifiable) adult (Check all that apply)  Sibling  Home  Other youth  School  Other, Specify:_________  Community 7. Was a report filed ? (e.g. Police, Child Protective  Other, Specify: Services) 0 No 1 Yes 99 Unknown ____________________________ 8. Did this maltreatment/abuse ever involve oral,  Unknown vaginal, or anal penetration? 5. Please identify the perpetrator(s). (Check all that  No apply)  Yes  Parent  Unknown  Other adult relative

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Trauma Detail, Physical Assault

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience. 4. Please indicate the setting(s) of the experience. (Check only one) 1 One-time event 2 Repeated (Check all that apply) exposure 99 Unknown  Home 3. Please describe the type(s) of experience. (Check  School all that apply)  Community  Experienced  Other, Specify:  Witnessed ____________________________  Vicarious  Unknown  Unknown 5. Please identify the perpetrator(s). (Check all that apply)

11  Parent  Other adult relative  Unrelated (but identifiable) adult  Sibling  Other youth  Stranger  Unknown 6. Was serious injury inflicted? 0 No 1 Yes� If YES, to whom:  Child a Detail,

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 Parent  Unknown Other adult relative  Unrelated (but identifiable) adult  Sibling  Other youth  Other, Specify:_________ 7. Was a weapon used? 0 No 1 Yes 99 Unknown 8. Was a report filed? (e.g. Police, Child Protective Services) 0 No 1 Yes 99 Unknownraum

Emotional Abuse/Psychological Maltreatment

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience. 5. Please identify the perpetrator(s). (Check all that (Check only one) apply)  One-time event  Parent  Repeated exposure  Other adult relative  Unknown  Unrelated (but identifiable) adult 3. Please describe the type(s) of experience. (Check  Sibling all that apply)  Other youth  Experienced  Stranger  Witnessed  Unknown  Vicarious 6. Please identify the type of maltreatment involved.  Unknown (Check all that apply) 4. Please indicate the setting(s) of the experience.  Emotional abuse (Check all that apply)  Emotional neglect  Home  Verbal abuse  School  Excessive demands  Community  Other,  Other, Specify: Specify_____________________________ ____________________________  Unknown  Unknown

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Trauma Detail, Neglect

Complete the following if experience of this trauma type is indicated on the General Trauma Information Form. 1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Other, Specify: (Check only one) ____________________________  One-time event  Unknown  Repeated exposure 5. Please identify the perpetrator(s). (Check all that apply)  Unknown 3. Please describe the type(s) of experience. (Check  Parent all that apply)  Other adult relative  Experienced  Unrelated (but identifiable) adult  Witnessed  Sibling  Vicarious  Other youth  Unknown  Stranger 4. Please indicate the setting(s) of the experience.  Unknown (Check all that apply) 6 . Please identify the type of neglect involved.  Home (Check all that apply)  School  Physical  Community  Medical  Educational

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Other, Specify_____________________________

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Trauma Detail, Domestic Violence

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Unknown

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Other adult relative (Check only one)  Unrelated (but identifiable) adult  One-time event  Sibling  Repeated exposure  Other youth  Unknown  Stranger 3. Please describe the type(s) of experience. (Check  Unknown all that apply) 6. Was a weapon used? 0 No 1 Yes 99 Unknown  Experienced 7. Was serious injury inflicted? 0 No 1 Yes� If YES, to  Witnessed whom:  Vicarious  Child  Unknown  Parent 4. Please indicate the setting(s) of the experience.  Unknown Other adult relative (Check all that apply)  Unrelated (but identifiable) adult  Home  Sibling  Other, Specify:  Other youth ____________________________  Other, Specify:_________  Unknown 8. Was a report filed ? (e.g. Police, Child Protective 5. Please identify the perpetrator(s). (Check all that Services) 0 No 1 Yes 99 Unknown apply)  Parent

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Trauma Detail, Illness/Medical

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience. 4. Please indicate the setting(s) of the experience. (Check only one) (Check all that apply)  One-time event  Home  Repeated exposure  Hospital  Unknown  Extended care facility 3. Please describe the type(s) of experience. (Check  Other, Specify: all that apply) ____________________________  Experienced  Unknown  Witnessed 5. Was the child’s condition life-threatening? 0 No 1 Yes 99 Unknown  Vicarious  Unknown

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Trauma Detail, Serious injury/accident

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Unknown (Check only one) 4. Please indicate the setting(s) of the experience.  One-time event (Check all that apply)  Repeated exposure  Home  Unknown  School 3. Please describe the type(s) of experience. (Check  Community all that apply)  Other, Specify:  Experienced ____________________________  Witnessed  Unknown  Vicarious

5. Please specify type of accident/injury(s).: (Check all that apply)  Motor vehicle  Dog bite  Near drowning  Accidental shooting  Other, Specify: ____________________________  Unknown

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6. Was permanent disability/death inflicted? 0 No 1 Yes� If YES, to whom:  Child  Parent  Unknown Other adult relative  Unrelated (but identifiable) adult  Sibling  Other youth  Other, Specify:_________

Trauma Detail, Natural Disasters

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Industrial (Check only one)  Other, Specify:  One-time event ____________________________  Repeated exposure  Unknown  Unknown 5. Was serious injury inflicted? 0 No 1 Yes� If YES, to 3. Please describe the type(s) of experience. (Check whom: all that apply)  Child  Experienced  Parent  Witnessed  Unknown Other adult relative  Vicarious  Unrelated (but identifiable) adult  Unknown  Sibling 4. Please specify type of disaster(s) involved. (Check  Other youth all that apply)  Other, Specify:_________  Earthquake 6. Did the child/family evacuate their home? 0 No 1  Hurricane Yes 99 Unknown  Flood 7. Was the child’s home severely damaged or destroyed? 0 No 1 Yes 99 Unknown  Tornado  Fire

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Trauma Detail, Kidnapping/Abduction

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience. 4. Please identify the perpetrator(s). (Check all that (Check only one) apply)  One-time event  Parent  Repeated exposure  Other adult relative  Unknown  Unrelated (but identifiable) adult 3. Please describe the type(s) of experience. (Check  Sibling all that apply)  Other youth  Experienced  Stranger  Witnessed  Unknown  Vicarious 5. Was a weapon used? 0 No 1 Yes 99 Unknown  Unknown

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Trauma Detail, Traumatic Loss or Bereavement

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience. 3. Please describe the type(s) of experience. (Check (Check only one) all that apply)  One-time event  Experienced  Repeated exposure  Witnessed  Unknown  Vicarious

14  Unknown 4. Please identify the people lost. (Check all that apply)  Parent  Other adult relative  Unrelated (but identifiable) adult  Sibling  Other youth  Stranger  Unknown 5. Was the loss/bereavement due to death? 0 No 1 Yes 99 Unknown 6. If loss was due to death, please specify cause(s) of death. (Check all that apply)  Natural causes/illness

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 Violence  Accident  Disaster  Terrorism, War, Political violence  Other, Specify_____ 7. If loss is not due to death, was caregiver removed from home? 0 No 1 Yes 99 Unknown 8. If caregiver(s) was removed from home, please specify reason(s). (Check all that apply)  Divorce  Incarceration  Hospitalization (medical or psychiatric)  Other, Specify_________ 9. Was child removed from the home? (e.g., Foster care, other out-of home) 0 No 1 Yes 99 Unknown

Trauma Detail, Forced Displacement

1. When was this trauma revealed/ known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience. 3. Please describe the type(s) of experience. (Check (Check only one) all that apply)  One-time event  Experienced  Repeated exposure  Witnessed  Unknown  Vicarious  Unknown

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Trauma Detail, Impaired Caregiver

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Sibling (Check only one)  Other youth  One-time event  Stranger  Repeated exposure  Other, Specify:  Unknown ____________________________ 3. Please describe the type(s) of experience. (Check  Unknown all that apply) 5. The impairment was due to?  Experienced (Check all that apply)  Witnessed  Drug use/abuse/addiction  Vicarious  Caregiver mental health  Unknown impairment/disorder 4. Please identify the impaired caregiver(s). (Check  Caregiver medical illness all that apply)  Other  Parent  Unknown  Other adult relative  Unrelated (but identifiable) adult

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Trauma Detail, Extreme Interpersonal Violence (Not reported elsewhere)

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Experienced (Check only one)  Witnessed  One-time event  Vicarious  Repeated exposure  Unknown  Unknown 4. Please indicate the setting(s) of the experience. 3. Please describe the type(s) of experience. (Check (Check all that apply) all that apply)  Home

15   

School Community Other, Specify: ____________________________  Unknown 5. Please identify the perpetrator(s). (Check all that apply)  Parent  Other adult relative  Unrelated (but identifiable) adult  Sibling  Other youth  Stranger  Unknown 6. Please indicate the type(s) of violence. (Check all that apply)  Robbery

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 Assault  Homicide  Suicide  Other, Specify: _________________  Unknown 7. Was a weapon used? 0 No 1 Yes 99 Unknown 8. Was serious injury inflicted? 0 No 1 Yes� If YES, to whom:  Child  Parent  Unknown Other adult relative  Unrelated (but identifiable) adult  Sibling  Other youth  Other, Specify:_________

Trauma Detail, Community Violence (Not reported elsewhere)

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Other, Specify: (Check only one) ____________________________  One-time event  Unknown  Repeated exposure 5. Was anyone seriously injured or killed? 0 No 1 Yes� If YES, to whom:  Unknown 3. Please describe the type(s) of experience. (Check  Child all that apply)  Parent  Experienced  Unknown Other adult relative  Witnessed  Unrelated (but identifiable) adult  Vicarious  Sibling  Unknown  Other youth 4. Please indicate the setting(s) of the experience.  Other, Specify:_________ (Check all that apply) 6. Was the violence gang-related? 0 No 1 Yes 99  School Unknown  Community

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Trauma Detail, School Violence (Not reported elsewhere)

1. When was this trauma revealed/known (to the clinician)? Baseline Other, please provide date: _ _/_ _ _/_ _ _ _ 2. Please describe the frequency of the experience.  Bullying (Check only one)  Classmate suicide  One-time event  Other,  Repeated exposure Specify_____________________________  Unknown  Unknown 3. Please describe the type(s) of experience. (Check 5. Was serious injury inflicted? 0 No 1 Yes� If YES, to all that apply) whom:  Experienced  Child  Witnessed  Teacher/staff  Vicarious  Unknown Sibling  Unknown  Other youth 4. Please identify the type(s) of violence. (Check all  Other, Specify:_________ that apply)  School shooting

APPENDIX B: Indicators of Severity of Problems All responses should be the Indicator of Severity for problems experienced within the past month. 1. Academic problems (e.g., Problems with school work or grades) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 2. Behavior problems in school or daycare (e.g., Getting into trouble, detention, suspension, expulsion) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 3. Problems with skipping school or daycare (e.g., Where he /she skipped at least 4 days in the past month, or skipped parts of the day on at least half of the school days) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 4. Behavior problems at home or community (e.g., Violent or aggressive behavior; breaking rules, fighting, destroying property, or other dangerous or illegal behavior) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 5. Suicidality (e.g., Thinking about killing himself/herself or attempting to do so) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 6. Other self-injurious behaviors (e.g., Cutting him/herself, pulling out his/her own hair) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 7. Developmentally inappropriate sexualized behaviors (e.g., Saying or doing things about sex that children his/her age do not usually know) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 8. Alcohol use (e.g., Use of alcohol) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 9. Substance use (e.g., Use of illicit drugs or misuse of prescription medication) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 10. Attachment problems (e.g., Difficulty forming and maintaining trusting relationships with other people) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 11. Criminal activity (e.g., Activities that have resulted in being stopped by the police or arrested) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 12. Running away from home (e.g., Staying away for at least one night) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 13. Prostitution (e.g., Exchanging sex for money, drugs or other resources) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem 14. Child has other medical problems or disabilities (e.g., Chronic or recurrent condition that affects the childâ&#x20AC;&#x2122;s ability to function) 0 Not a problem 99 Unknown 1 Somewhat/sometimes a problem 2 Very much/often a problem

APPENDIX C: DSM-IV-TR DIAGNOSTIC CRITERIA FOR PTSD A. The person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the personâ&#x20AC;&#x2122;s response involved intense fear, helplessness or horror B. The traumatic event is persistently re-experienced in one (or more) of the following ways: (1) recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions (2) recurrent distressing dreams of the event (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated) (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that arouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities (5) feeling of detachment or estrangement from others (6) restricted range of affect (e.g., unable to have loving feelings) (7) sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

APPENDIX D: MOOD AND FEELINGS Q Mood and Feelings Questionnaire-Child Version Please darken the circle next to the statement that best describes you in the PAST TWO WEEKS. Not true Sometimes 0 1 1. I felt awful or unhappy. 2. I didn't enjoy anything at all. 3. I was less hungry than usual. 4. I ate more than usual. 5. I felt too tired I just sat around and did nothing. 6. I was moving and walking more slowly than usual 7. I was very restless. 8. I felt I was no good anymore. 9. I blamed myself for things that weren't my fault. 10. It was hard for me to make up my mind. 11. I felt grumpy and upset with my parents. 12. I felt like talking less than usual. 13. I was talking more slowly than usual. 14. I cried a lot. 15. I thought there was nothing good for me in the future. 16. I thought that life wasn't worth living. 17. I thought about death or dying. 18. I thought my family would be better off without me. 19. I thought about killing myself 20. I didn't want to see my friends. 21. I found it hard to pay attention or concentrate. 22. I thought bad things would happen to me. 23. I hated myself. 24. I felt I was a bad person. 25. I thought I looked ugly. 26. I worried about aches and pains. 27. I felt lonely. 28. I thought nobody really loved me. 29. I didn't have any fun at school. 30. I thought I could never be as good as other kids. 31. I felt I did everything wrong. 32. I didn't sleep as well as I usually sleep. 33. I slept a lot more than usual.

True 2

POST-TRAUMATIC STRESS DISORDER SELF-TEST If you suspect that you may suffer from Post-Traumatic Stress Disorder (PTSD), complete the self-test form below. Simply circle either 'YES' or 'NO' in answer to the questions. When you have completed the test, print the page and show the results to your Doctor, who will be able to help you. 1. 2.

3. 4. 5. 6. 7. 8. 9. 10. 11.

12.

13. 14.

15.

Have you experienced or witnessed a life-threatening event that caused intense fear, helplessness or horror? This includes sexual abuse. YES/NO Do you re-experience the event in at least one of the following ways? 2.1. Repeated, distressing memories and/or dreams? YES/NO 2.2. Acting or feeling as if the event was happening again? (flashbacks or re-living it). YES/NO 2.3. Intense physical and/or emotional distress when you are exposed to things that remind you of the event? YES/NO Do you avoid reminders of the event and feel numb, compared to the way you felt before? YES/NO Do you avoid thoughts, feelings and conversations about the event? YES/NO Do you avoid activities, places or people who remind you of it? YES/NO Have you blanked on parts of the detail? YES/NO Are you losing interest in significant activities in your life? YES/NO Are you feeling detached from other people? YES/NO Do you feel as if your range of emotions is restricted? YES/NO Do you feel as if your future is diminished in terms of marriage, children or a normal life span? YES/NO Are you troubled by two or more of the following: 11.1. Problems sleeping? YES/NO 11.2. Irritability or outbursts of anger? YES/NO 11.3. Problems concentrating? YES/NO 11.4. Feeling 'on-guard'? YES/NO 11.5. An exaggerated startle response? YES/NO Having more than one illness at the same time can make it difficult to diagnose and treat the different conditions. Illness that sometimes complicate an anxiety disorder include depression and substance abuse. With this in mind, please take a moment to answer the following: Have you experienced changes in sleeping or eating habits? YES/NO More days than not, do you feel: 14.1. Sad or Depressed? YES/NO 14.2. Disinterested in life? YES/NO 14.3. Worthless or guilty? YES/NO During the last year, has the use of alcohol or drugs: 15.1. Resulted in your failure to fulfill responsibilities with work, school or family? YES/NO 15.2. laced you in a dangerous situation, such as driving a car under the influence? YES/NO 15.3. Been responsible for you being arrested? YES/NO 15.4. Continued despite causing problems for you and your loved ones? YES/NO

Reference: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington DC, American Psychiatric Association.

http://rapecrisis.org.za/virtual-tour-of-the-criminal-justice-system/

Rape Trauma Syndrome No person exposed to severe trauma is immune to suffering and the signs of that suffering are referred to as symptoms. When these symptoms can be grouped as a pattern over time, they are referred to as a syndrome. Once the pattern becomes entrenched or unlikely to change, and affect a person’s functioning in a permanent way it is referred to as a disorder and is regarded as a mental illness. Rape Trauma Syndrome (RTS) is the medical term given to the response that survivors have to rape. It is very important to note that RTS is the natural response of a psychologically healthy person to the trauma of rape so these symptoms do not constitute a mental disorder or illness. The most powerful factor in determining psychological suffering or damage is the character of the traumatic event itself. Individual personality characteristics count for little in the face of overwhelming events. Physical harm or injuries are also not as great a factor since individuals with little or no physical harm may yet be severely affected by their exposure to a traumatic situation. Before looking at the effects of rape it is therefore important to first examine the character of the trauma that is rape. Not only is there the element of surprise, the threat of death and the threat of injury, there is also the violation of the person that is synonymous with rape. This violation is physical, emotional and moral and associated with the closest human intimacy of sexual contact. The intention of the rapist is to profane this most private aspect of the person and render his victim utterly helpless. The character of the event is thus connected to the perpetrator’s apparent need to terrorise, dominate and humiliate the victim. The victim is therefore most likely to see his actions as motivated by deliberate malice, a malice impossible for her to understand. Rape by its very nature is intentionally designed to produce psychological trauma. It is form of organised social violence comparable only to the combat of war, being but the private expression of the same force. We get nowhere in our understanding of Rape Trauma Syndrome if we think of rape as simply being unwanted sex. Where combat veterans suffer Post Traumatic Stress Disorder, rape survivors experience similar symptoms on a physical, behavioural and psychological level. PHYSICAL SYMPTOMS OF RAPE TRAUMA SYNDROME Physical symptoms are those things which manifest in or upon the survivor’s body that are evident to her and under physical examination by a nurse or doctor. Some of these are only present immediately after the rape while others only appear at a later stage.          

Immediately after a rape, survivors often experience shock. They are likely to feel cold, faint, become mentally confused (disorientated), tremble, feel nauseous and sometimes vomit. Pregnancy. Gynecological problems. Irregular, heavier and/or painful periods. Vaginal discharges, bladder infections. Sexually transmitted diseases. Bleeding and/or infections from tears or cuts in the vagina or rectum. A soreness of the body. There may also be bruising, grazes, cuts or other injuries. Nausea and/or vomiting. Throat irritations and/or soreness due to forced oral sex. Tension headaches. Pain in the lower back and/or in the stomach. Sleep disturbances. This may be difficulty in sleeping or feeling exhausted and needing to sleep more than usual.

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Eating disturbances. This may be not eating or eating less or needing to eat more than usual. BEHAVIOURAL SYMPTOMS OF RAPE TRAUMA SYNDROME Behavioural symptoms are those things the survivor does, expresses or feels that are generally visible to others. This includes observable reactions, patterns of behaviour, lifestyle changes and changes in relationships.

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Crying more than usual. Difficulty concentrating. Being restless, agitated and unable to relax or feeling listless and unmotivated. Not wanting to socialize or see anybody or socializing more than usual, so as to fill up every minute of the day. Not wanting to be alone. Stuttering or stammering. Avoiding anything that reminds the survivor of the rape. Being more easily frightened or startled than usual. Being very alert and watchful. Becoming easily upset by small things. Relationship problems, with family, friends, lovers and spouses. Irritability, withdrawal and dependence are factors which effect this. Fear of sex, loss of interest in sex or loss of sexual pleasure. Changes in lifestyle such as moving house, changing jobs, not functioning at work or at school or changes to her appearance. Drop in school, occupational or work performance. Increased substance abuse. Increased washing or bathing. Behaving as if the rape didn’t occur, trying to live life as it was before the rape, this is called denial. Suicide attempts and other self-destructive behavior such as substance abuse or self mutilation. PSYCHOLOGICAL SYMPTOMS OF RAPE TRAUMA SYNDROME Psychological symptoms are much less visible and can in fact be completely hidden to others so survivors need to offer this information or be carefully and sensitively questioned in order to elicit them. They generally refer to inner thoughts, ideas and emotions.

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Increased fear and anxiety. Self-blame and guilt. Helplessness, no longer feeling in control of her life. Humiliation and shame. Lowering of her self esteem Feeling dirty or contaminated by the rape Anger Feeling alone and that no one understands. Losing hope in the future. Emotional numbness. Confusion Loss of memory. Constantly thinking about the rape.

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Having flashbacks to the rape, feeling like it is happening again. Nightmares Depression. Becoming suicidal. There are many influences on the manner in which each individual survivor of sexual violence copes and on the length of time the symptoms may be present. These factors include:

       

Support systems The relationship with the offender The degree of the violence used Social and cultural influences Previous experience with stress Ability to cope with stress Attitude of those immediately contacted after the assault The age and developmental stage of the survivor (adolescent survivors are more vulnerable) It is important that we recognise that survivors will not respond in the same ways, as comparing two case histories can show. While most survivors will experience these symptoms, some survivors may only experience a few of these symptoms while others may experience none at all. We must be careful not to judge whether someone has been raped by the number of symptoms that they display. Because most survivors are afraid to tell anyone that they have been raped it is often not easy to observe their reaction, or recognise them without the survivor’s own account – and this she is unlikely to give easily. It has been observed through clinical studies that almost all rape survivors suffer severe and long lasting emotional trauma. The most significant factors that cause this appear to be a combination of the following features of the assault experience. It is sudden It is perceived as life threatening Its apparent purpose is to violate the survivor’s physical integrity and/or render her helpless. The survivor is forced to participate in the crime. The survivor cannot prevent the assault or control the assailant, her normal coping strategies have failed. Thus she becomes a victim of someone else’s aggression. The trauma is usually compounded by the myths, prejudice and stigma associated with rape. Survivors who have internalised these myths have to fight feelings of guilt and shame. The burden can be overwhelming especially if the people they come into contact with reinforce those myths and prejudices. This is why it is essential that all legal, medical and police procedures must not cause further trauma to survivors who must be given all possible support to overcome and survive the ordeal. Courts are now beginning to use evidence of this kind in the trial stage of a court case as well as at the sentencing stage where the effect that the rape has had on the victim’s life is taken into consideration when sentencing the perpetrator. However it is plain to see that there are distinct psychological clues, left in the survivor’s mind, that add up to evidence of trauma of a very particular character that we know as the crime of rape.

Phases of Recovery (Rape Crisis Cape Town) When considering the phases of recovery in this paper we are looking at recovery during counselling, not recovery without counselling. Recovery without counselling is of course possible especially for those survivors with a good support system, a healthy environment and strong inner resources. But it is useful to see a process of recovery within counselling as a guide for counsellors on how to move forward from session to session with a particular client, to be able to anticipate problems and issues and to offer consistent support to the survivor. Bear in mind that we are looking here at the emotional aspects of recovery with the medical and legal aspects dealt with elsewhere in other readings available to counsellors. Ideas about counselling someone towards recovery from rape must take several factors into account, such as the person’s individual response to trauma, the person’s interaction with their environment, the fact that recovery unfolds in a series of progressive, identifiable stages as well as a definition of recovery that has many sides or aspects to it. With this in mind we hope to develop some useful ways of thinking about trauma, treatment and recovery. Responses to trauma are influenced by the following factors:       

The person’s life history in the year before and after the trauma The nature of the traumatic event Whether there was more than a single event The potential for secondary trauma from police and doctors The potential for secondary trauma from people close to the survivor The support, or lack of support of family and friends The social and political context the survivor lives in So the person’s ability to cope with the trauma and its effects are part of a complex interaction of people, situations and events. In other words the “ecology” of the victim’s experience comes from the interaction between the person, the event and the environment. Treatment and counselling must be tailored to respond to the individual and unique events and circumstances of a particular survivor. The stages of recovery from rape can be looked at in a number of different ways but a three-stage model used in many victims of violence programs is the simplest and most useful. The understanding behind this model is that a victim of rape will feel a sense of helplessness, disconnected from herself and others and will have lost a sense of meaning in her life as a result of the trauma she experienced. Empowerment, creating new connections and uncovering a new sense of meaning are the prime goals of the three-stage treatment model. Before examining these in more detail, the role of the counsellor needs to be briefly outlined.

The Role of the Counselor Control over the recovery process rests with the survivor. The relationship between the survivor and the counsellor is one among many and it is by no means the most important one. The counsellor’s role is as a witness, an ally and expert educator about trauma and recovery. As a witness the counsellor respects the client’s autonomy by being disinterested and neutral in that she abstains from using her power over the client to gratify her own personal needs, does not take sides in the client’s inner conflicts and does not try to direct the client’s life decisions. As an ally she agrees to place all the resources, knowledge and skills she possesses at the client’s disposal in order to promote the client’s recovery. The counsellor fulfils the

role of expert educator by sharing information about rape and trauma and the recovery process with the client and in doing so she equalises her relationship with the client and enables her to know as much as the counsellor does. Every counsellor needs to hold strongly to the knowledge that rape shapes the survivor’s current daily experience, including the counselling relationship. The counsellor has to put considerable energy into creating a genuinely respectful and collaborative relationship and one that the client can safely accept. Trauma counsellors must be able to accept, validate and contain the deep and disruptive emotional states that trauma arouses. They must also be able to offer nurturance without infantilising survivors. They must be able to address perceptions twisted by trauma without disempowering or shaming the survivor. The first goal of counselling must focus on the establishment of safety. The alliance between counsellor and survivor is formed initially around the common goal of ensuring a reasonable degree of safety and no other work should be attempted until this has been achieved. However, in this area there is much to be done and no shortage of tasks for both counsellor and survivor to perform. Safety needs to be achieved around a list of different areas in the person’s life as follows:       

Physical safety from further harm by the perpetrator Regular healthy patterns of eating, sleeping and exercise Freedom from self destructive behaviors Freedom from the symptoms of Rape Trauma Syndrome A safe home to live in Adequate work and money Self protection within the community For survivors of long-term abuse and childhood sexual abuse this phase may take a long time because self-care and being able to comfort themselves are not patterns ever fully established in the development of abused children. Developmental problems take years of time and professional intervention to resolve, hence Rape Crisis does not take on clients such as these. We do however facilitate our clients’ access to the resources they do need that can help them and a counsellor would see a client until referral is successful, thus fulfilling the goal of the initial stage in part before handing it over to a more appropriate person. The concept of a facilitated referral is more useful than simply passing the client on to another service and leaving it at that. Survivors from poverty stricken and oppressed communities will also need much time and support to work through this phase as their survival needs will not be easy to encompass and they may be forced to live in violent homes and communities. Rape Crisis has made a concerted effort to link itself with organisations and resources aimed at poverty alleviation and community development but counsellors are also called upon to be creative and innovative in supporting clients towards safety. A client cannot attempt to recover from rape until she can be sure of food on the table and a sheltered place to sleep. There are as many strategies for support as there are areas needing safety and these must all be mobilised where needed. Some examples are as follows:

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Information and literature on rape and on trauma and its symptoms Information on how to recover from trauma Psychiatric medication for regulating sleep, depression and anxiety Hard exercise to manage stress Daily logs to chart reactions and emotions

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Homework tasks to help manage these Concrete safety plans Gradually forming reliable relationships for support Visualization, breathing exercises and meditation Self help programs Social agencies Admission to various kinds of hospital programs (day treatment, in patient, emergency psychiatric services) Details of all these strategies will be available for counsellors in the counselling offices and the office teams and supervision groups are available to discuss other ideas and for problem solving. For instance a really fragile client who may experience her toughest times when she can’t sleep in the early hours of the morning could be given numbers for the 24 hour counselling services available and be encouraged to use them.

Stage Two: Remembrance and Mourning Once safety on all levels has been accomplished the focus of the work shifts to an active, in-depth exploration of the traumatic experiences. This work is vital to the recovery process and failure to address it a common error in the treatment of survivors but at the same time addressing it in a premature or over zealous way could be equally seen as a failure. A careful review with the client should precede the decision to begin active uncovering work and she should give her full permission before moving on. It should not proceed unless the tasks of establishing safety have been thoroughly covered. Her timing and her pace are the deciding factors that counsellors should follow and support and by this time the alliance between counsellor and survivor should be strong enough to go ahead with. She must be ready to tell the story of her trauma and to tell it completely, in depth and in detail. The basic principles of empowerment continue to apply throughout this process. The choice to confront the horrors of the past rests with the survivor. The counsellor plays the role of witness and companion. Both must be brave and feel secure in their differing roles in order to be able to do this. Freud describes this kind of uncovering well: “The patient must find the courage to direct [her] attention to the phenomena of her illness. Her illness must no longer seem to her contemptible but must become an enemy worthy of her mettle, a piece of her personality, which has solid ground for its existence, and out of which things of value for her future life have to be derived. The way is thus paved…for a reconciliation with the repressed material which is coming to expression in her symptoms, while at the same time place is found for a certain tolerance for the state of being ill.” Reference: Sigmund Freud, Remembering, Repeating and Working Through, 1914 in Standard Edition, Vol. 12, trans J. Strachey, Hogarth Press, London, 1958. In this respect the illness he is speaking of can quite simply be seen as the symptoms of Rape Trauma Syndrome (bearing in mind that Feminist theory does not regard this as an illness as such but rather as an injury.) A rape survivor can come to see the symptoms of RTS as being the expression of the trauma she suffered while at the same time, having gone through the process of establishing safety, is able to tolerate them to some degree.

The purpose of this part of the process is not a sudden catharsis, or sudden release of emotion by association with the trauma that is its cause but rather a slow and careful exploration of memories, thoughts and feelings as the client is able to cope with them. Thus she integrates the trauma into herself and is therefore free to reconnect with herself and others. She remembers what happened, what she thought about at the time and how she felt but is not called upon to relive them all at once; this is a mastery experience rather than a re-enactment or debriefing. The counsellor may even be called upon to slow a client down if she becomes flooded with memories and emotions. Before the telling of the story the survivor should be encouraged to tell the counsellor something of her life before the rape so that she can own the person she was before it happened and begin to restore the flow of her life. She should be encouraged to talk about her important relationships, her dreams and ideals and her previous struggles and conflicts. Then she is asked to put the story into words, initially simply as a statement of the facts in detail and in the order in which they occurred. If she skips forward she needs to brought back, if she goes off on a tangent or rambles she needs to be refocused and bit by bit taken through the event right through to completion. At each point the counsellor needs to also ask the client what she was thinking at the time and what was going through her mind and what emotions she felt, what physical sensations she had and really to give as much detail to the description of her inner experiences as to that of the outer events. If her symptoms worsen dramatically then that is taken as a signal to slow down or backtrack. She must however know that the process could be painful and that she’ll feel vulnerable at this time and might not be at her best at work, at home and in relationships. She needs to be able to draw on the support created in the initial phases of safety and learn to tolerate some increase in the intensity of her symptoms. She should also be sustained by the hope of new meaning in her life through integrating the trauma, or bringing all the parts of herself, both the traumatised and “healthy” aspects of who she is, into a whole. In recounting the thus far unspeakable story she may come up against unanswerable questions like why this happened or why it had to happen to her. Both client and counsellor must be prepared for the uncertainty of knowing there may not be answers. Evil is meaningless and empty and completely arbitrary in who it finds; no human explanation is possible and no victim deserving. Both have to face the possibility of these bleak conclusions and in doing so have their faith and beliefs challenged. To accept this is to allow for the trauma to be transformed. If not the survivor might push for a premature closure of the story based on the facts alone in an attempt to avoid the emotional aspects that lead to feelings of conflict and uncertainty; and in so doing leave out what is essential to the healing. What happens is that the abnormal processing of the trauma is changed as it is processed or worked through in this gentle but deep and systematic way. The telling of it in the right order and with all the rich detail of feelings and sensations brings relief. But this is still not the end. Now she has to feel the grief at her losses and mourn them. Ironically this, the most relieving part of the process, is the one most survivors dread the most, fearing they will not cope with the overwhelming emotions. Some also feel mourning is a sign of defeat, showing that the perpetrator has won in some way. For these reasons it is important for counsellors to reframe grieving as an act of release and courage rather than of being overwhelmed and humiliated. Only by grieving can she reconnect with the part of her that is indestructible. But many clients resist this part because it is so difficult and this can lead to stagnation, the most common problem with this phase of treatment. Resistance also wears many disguises: most frequently it appears as a fantasy of magical resolution through revenge, forgiveness or compensation. Counsellors must make sure they don’t collude with their clients’ fantasies or they will remain stagnating and frustrated by the

lack of therapeutic progress. The counsellor must be aware of the potential for resistance and be able to work through this. In revenge the roles of victim and perpetrator are reversed and the survivor imagines this will rid her of the feelings of shame and helplessness – feelings all exacerbated by the remembering process – and immediately restore her sense of power. But images of revenge can be just as traumatic as those of the event itself and can also be frustrating since revenge can never change what happened. In grieving she can vent her feelings of helpless fury and transform them into the healthier and more satisfying ones of righteous indignation. The fantasy of forgiveness is also a search for empowerment and an attempt to exorcise the trauma but through love rather than hate. Such forgiveness is out of reach for most ordinary humans – most spiritual traditions agree that forgiveness and retribution are both divine. And even divine forgiveness requires the perpetrator seek it and offer confession, repentance and atonement. For human beings healing is not about exorcism it is about adaptation and integration and the rediscovering of restorative love in her own life before ever she can consider extending it to the perpetrator. She will find this through grieving not through forgiveness. The fantasy of compensation is one of the most difficult of the resistances to mourning to overcome because the legitimacy of the survivors desire for it in the face of the injustice she endured is completely understandable. She feels entitled to compensation and her quest to achieve it can be an important part of the full healing journey. However by tying her fate to that of the perpetrator she does not liberate herself from his influence but holds her recovery hostage to the miracle of his acknowledging what he did and offering public apology or humiliating punishment. She might wait years for this wish to come true but by grieving she liberates herself to seek justice through the more formal social channels and gives herself a greater chance of enduring its rigours. Risks for the survivor in grieving are that in facing despair she will succumb to depression and confront thoughts of suicide. She feels it impossible to live in a world where such cruelty exists. She wants to escape from her misery and has lost all faith in love. It’s important here to keep her in touch with her capacity to love no matter how small and insignificant it may seem. Visualisation and soothing imagery are also useful here and usually the suicidal feelings and depression pass – they are part of a necessary transition. For many survivors the time passes slowly and seems endless and they ask how long it must go on. It cannot be hurried nor can it be by-passed and there is no strait answer to the question but this.

Stage Three: Reconnecting The third stage of recovery involves the active pursuit of social reconnection. In the process of establishing mutual, non-exploitive peer relationships the survivor will often reassess and renegotiate long-standing relationships with friends, lovers and family. Issues of boundaries may be explicitly addressed for the first time. She may wish to disclose the rape for the first time to people close to her who didn’t know it happened. A new level of transformation of the trauma takes place and new meaning is created. Having come to terms with the past the survivor now needs to create a new future. If there is one thing that exemplifies this part of the process it is the survivor’s learning to know and rely upon herself. She no longer feels possessed by the trauma; she possesses it as a part of herself. She can now look at, decide and become the person that she wants to be. She discovers the parts of herself that she most values, from the time before the trauma, from the trauma itself and from the process of her recovery. She can take up old and new hopes and dreams. It takes courage; she may fear failure and

disappointment, she must move beyond the limited stance of “victim” and learn to thrive. She must dare to define her ideal self and take up its challenge. At the same time as embarking on this adventure her life becomes more ordinary as she lets go of her symptoms. She sleeps and eats well, can function at home and in her job, she feels calmer within herself and gets on with others in the daily rhythms of her existence. The peaceful, even boring, norms of daily living may be scary at first and even a little strange as she waits for something to come along and disrupt it all again. Helping her believe in the wonder of ordinariness is part of the counsellor’s role at this time. She may need affirmation from her counsellor or have herself discovered positive aspects that the trauma showed her about herself but respect for her strengths is a very crucial thing for her counsellor to offer at this time. Help her to celebrate her survival and more, her ability to move on. Learning to fight is another aspect of this phase, where clients learn to take back their power. Sometimes this is a conscious choice to face danger that could express itself in doing something like a self-defence course or taking up martial arts training. It could also be a renewed determination to bring the perpetrator to justice and to take up the challenge of seeing the pathway through the Criminal Justice System to a close. Some survivors may look at characteristic ways of handling situations and question their own submissiveness or passivity. As a result of this they might look for more assertive ways of handling situations and actively learn how to be more assertive. Some may challenge women’s traditional roles in society and change their more stereotypically feminine attitudes. Provided she fully realises the perpetrator’s responsibility for the crime committed against her then she should be free to explore aspects of being that render her more vulnerable to exploitation but not until she can locate the blame for what happened to her with the rapist. She has also regained her capacity to trust in others and in the safety of her life. She can once again take initiative in friendships and other relationships. She can maintain her own point of view and boundaries, she does not drown in the emotions of other people or feel overwhelmed by her own; she can even risk deepening relationships. She can also focus on issues of identity and intimacy even though she might feel awkward and self-conscious. She can become ready to explore sexual intimacy and the process of arousal and orgasm without being bombarded by associations with the rape. However reclaiming ones own capacity for sexual pleasure is a deeply complex process and will have to have its own built in safety mechanisms to help the survivor feel completely in control at first before she allows herself to abandon control in favour of pleasure and connectedness. Some clients will need help with this and to be given access to resources other than those the counsellor can offer such as self help sex manuals and guidelines for exploring sexual intimacy in a safe way with a partner. Most importantly, if the survivor does not take up these challenges it is not for the counsellor to take responsibility for her life. The old saying “You can take a horse to water but you cannot make it drink” holds true here. No matter how thirsty you might think a survivor is to renew her connections to her life and a hopeful future if she is not going to do it for herself then no one is and counsellors just exhaust themselves in trying. Both counsellors and clients also have to realise that resolution of the trauma is never final; recovery is never complete. The impact of the rape continues to echo through the years, especially when there are other stresses and life crises to face. Marriage, divorce, birth and death will all hold the potential to reawaken traumatic symptoms. They must be reassured that the door to counselling remains open for them to re-enter as needs arise. Provided she can return her attention to the tasks of ordinary life rather than of survival and recovery. She has told her story and can move on.

Recovery Criteria So how do we know that the survivor has recovered? Mary Harvey at Cambridge Hospitalâ&#x20AC;&#x2122;s Victims of Violence program has developed seven domains through which to determine recovery as follows: Memory The survivor can choose to recall or not to recall the trauma. There are no gaps in memory and the survivor has a clear and coherent story or picture of what happened that can be integrated into their life story as a whole. Affect range and tolerance Feelings and emotions are not experienced only in extremes but can be felt, named and endured in a broad range of types and intensities. Memory and affect are linked Memories are recalled together with appropriate feelings and at an appropriate level. The survivor can have feelings in the present about what happened in the past and can remember what she felt at the time of the trauma without reliving the emotion itself. Symptom mastery Symptoms of Rape Trauma Syndrome have receded or become manageable. Self-esteem Feelings of self hate, blame, badness and shame are replaced by more realistic views of the self. Responsibility for the abuse is placed firmly with the perpetrator, the survivor can accept what they did to survive and is able to care for herself again. Attachment Feelings of isolation are replaced by a capacity to feel connected to others and distorted perceptions of others become more realistic. Meaning The survivor is able to create realistic meaning to the trauma, to acknowledge complex and contradictory views about reality and is able to feel a realistic sense of hope and optimism about the future. During each of the three stages of recovery in counselling each of the seven dimensions or domains must be considered in a kind of matrix. In this way the question how far along the road to recovery is this client can be answered and appropriate counselling offered. So someone who, for example, experiences important gaps in memory but instead experiences a lot of nightmares, bodily states or intense emotions unrelated to current events and who cannot understand the relationship between the gaps and the

symptoms would be in Stage One of recovery. The person who begins to see the relationship and to deliberately fill in the gaps while the symptoms consequently decrease would be in Stage Two while the person who fully understands the relationship and has filled in all the gaps and now seeks to remember who she was before the trauma and to knit the memories together in their proper places is in stage three. This step by step meticulous process takes time and energy and both counsellors and clients need a great deal of support during it. This model has value in matching a particular client to a particular focus in counselling and is therefore a valuable screening tool. It also provides a foundation from which to develop different types of interventions finely tuned to the recovering survivorâ&#x20AC;&#x2122;s changing needs. The Victims of Violence program is currently taking up the challenge of filling in the blocks and systematically describing the difference in each dimension for each stage. Itâ&#x20AC;&#x2122;s quite good for us that they havenâ&#x20AC;&#x2122;t done so because it gives us the freedom to explore and do so in a way that is meaningful to us in our own context. This is a process that perhaps not many counsellors will embrace but those that do will find it fascinating and useful to their clients.