Survivors West Yorkshire Ben's Place Virtual Counselling Pilot - Evaluation Report

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Survivors West Yorkshire Ben’s Place virtual counselling pilot Evaluation report April 2019

Natalie McKeown & Charlotte Russell

Beware of the Bull Ltd

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Contents Overview and key findings ................................................... 3 Background ........................................................................... 4 Methodology …………............................................................. 6 The need for the project ....................................................... 7 Summary of results ............................................................... 9 Case study ………………………………………………………………………… 15 Recommendations and further work ................................... 16 Appendices ........................................................................... 18 References ……………………………………………………………………….. 21

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Overview and key findings Survivors West Yorkshire is a registered charitable incorporated organisation (number 1168928) based in the city of Bradford in West Yorkshire. Established in 2000 with the aim of providing support for people who had been the victims of child sexual abuse or adult rape, the service initially supported victim-survivors mostly in the Bradford area, using a combination of offline support and email/ telephone-based support. Over the past 17 years, Survivors West Yorkshire (SWY) has expanded to help people from across the county, and in that time has supported over 3,000 survivors of sexual violence.

The charity secured funding in 2017 from the National Lottery Awards for All programme to run a one year pilot project delivering ‘virtual’ (cloud-based) counselling for male survivors of sexual violence. This evaluation study aims to assess how effective SWY’s one year virtual counselling pilot has been in achieving its stated outcomes: • Enabling male survivors to develop better coping skills in order to build resilience and self-confidence; • Through increased resilience and self-confidence, enabling survivors to seek out and take up opportunities such as employment and training which they have previously felt unable to do; and • By directly addressing the sexual abuse that men have experienced, to put them in a better position to work on overcoming the mental and physical ill-health and harmful behaviours that put their health at further risk.

Key findings of this study are: 1. Virtual counselling is an effective way for most male survivors of sexual violence to enable them to develop better coping skills and to build their resilience and self-confidence.

2. 67% of the clients supported via this pilot project sought out/took up opportunities which they previously felt unable to do as a result of this intervention. This figure rose to 80% for those clients with more sustained engagement (average 13 sessions) with the counselling.

3. The intervention has had a significant positive effect on clients’ mental health.

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Background SWY first started as a community-led organisation in 2000. Support for survivors at that time was very limited. In its early years, SWY pioneered the use of digital technology to meet the needs of survivors, with the aim of increasing the ability of survivors to be involved in informing policy and specialist service design. Over the past 18 years, SWY has delivered a virtual signposting service via email and phone, providing support to an average of 150 survivors each year.

Survivors West Yorkshire now focuses on providing support for male survivors, for whom there is – regionally and nationally – a far less diverse and prolific support offer than there is for female survivors. They currently offer: • Virtual counselling: a pilot project offering online counselling from qualified, specialist counsellors • Email support: emotional support & signposting for male survivors of child sexual abuse (CSA) and/or adult rape • SMS text message support: quick response, text-based emotional support • Telephone support: real-time, personal emotional support • Online self-help resources: for male survivors and those around them • Signposting to other services: e.g. local ISVA (Independent Sexual Violence Advocate) services SWY has forged innovative and evolving partnerships and collaborations with rape crisis services and other organisations in the sector, aiming to challenge the silence around male sexual violence wherever it was seen to be holding back safe and evidenced improvements for survivors – regardless of age, gender or experience.

As part of their partnership work, SWY pioneered UK workshops for male survivors (Victims No Longer) and those who support them (Healing the Healers) in partnership with Mike Lew, an internationally recognised specialist in psychotherapeutic interventions for men recovering from CSA. SWY has commissioned several rounds of research in recent years, which has resulted in the ‘A View from Inside the Box’ series of reports (published between 2004-2017). These reports have been developed with a focus of lobbying at all levels of government over the past 13 years.

The flagship virtual signposting service has been very successful and is well regarded across the statutory and voluntary sectors. With the latest advances in digital technology, SWY has been keen to take up new opportunities to develop this type of service provision, and are now in the process of expanding their service to include:

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• • • •

Voice counselling Email counselling Video counselling: real-time, face-to-face emotional support & counselling ‘Radio SWY’: an online radio station which will bring a range of perspectives and insights from around the world.

• Blog: offering different perspectives, disseminating research, signposting and sharing self-help resources • An online ‘one stop’ knowledge centre hub, collating resources for everything to do with supporting survivors of sexual violence.

Virtual support systems have been shown to provide great benefits for complex trauma populations: users report enjoying the ease of access and are shown to benefit from significant positive outcomesi. The use of online support systems has the added benefit of sustainability and efficiency (e.g. as evidenced in the recent Combat Stress pilot online counselling project reportii) – once the system is set up, it requires minimal maintenance, ensuring that project staff have maximum time to devote to direct service delivery.

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Methodology The evaluation comprised the following methodological elements: Desk-based research The evaluator carried out a literature review focusing on areas of local need and specific difficulties faced by male survivors of sexual violence. They also conducted an independent analysis of data collected by the project, consisting of: • Client scores over time on the 2 diagnostic questionnaires used by counsellors for this project – the Impact of Events Scale – Revised (IES-R), used to assess whether a client meets the diagnostic criteria for PTSD; and the Patient Health Questionnaire (PHQ-9), which is used to monitor severity of depression. Copies of these questionnaires are available at Appendix I and Appendix II • Counsellors’ session notes, providing an overall view of clients’ mental state on the day a session took place • Supporting data, including a report of qualitative feedback from counsellors, and web traffic analysis to track referral pathways

Observation The evaluator visited the organisation on 31st October 2018 and spoke with staff to gain an overall view of the project. Due to the sensitive nature of the issues presented by clients and their reluctance to engage with other services (this project is designed to reach survivors who have not felt able to engage with traditional sexual violence support services), it was not deemed appropriate for the evaluator to interview clients directly.

Online Survey In March 2019, 5 service users completed online surveys reviewing their experience of the virtual counselling service. Survey questions investigated service users’ selfassessment of the impact which Ben’s Place has had so far upon their physical and mental well-being. Each respondent had completed between 10 and 17 sessions, with an average of 13. Three respondents were referred by other services, one selfreferred via an internet search, and one was recommended by a friend. A copy of the online survey is included at Appendix III.

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The need for the project Official figures on annual reported male rape incidents have risen by over 800% since figures were first compiled in 1995 – from 150 to nearly 1,300. In the year to March 2016, police in England and Wales recorded 3,443 occurrences of sexual assault on males aged 13 and over, and 1,282 occurrences of rape of males aged 16 and overiii. Sexual violence crimes – and particularly male sexual violence crimes – are known to be drastically underreported. Knowing this, it is likely that the true number of male rape occurrences is much higher than the reported statistic.

The effects of sexual abuse and rape are pervasive and long-lasting. Adverse childhood experiences (ACEs), including sexual abuse or exploitation, can have lifelong effects on physical and mental health – and are directly implicated in causing early death. Children exposed to ACEs “are more likely to go on to develop health harming and antisocial behaviours, often during adolescence, such as binge drinking, smoking and drug use”iv. Men who have been exposed to ACEs report higher levels of all health harming behaviours than women who have been exposed to the same ACEs, and present with multiple and complex needs. The trauma manifests itself in physical, mental, emotional and behavioural symptoms, from the immediately evident – e.g. a post-traumatic psychotic episode – to the subtle – e.g. low self-esteem/lack of confidence. Male survivors of sexual abuse are ten times more likely to commit suicide than non-survivorsv.

Recorded adult rapes per 100,000 of adult population in West Yorkshire have been higher than the England and Wales figure every year since 2012/13. In 2015/16, West Yorkshire had the second highest level of recorded adult rapes, and the highest level of recorded child rapes of any area nationwide. Despite this, in the same time period West Yorkshire had the 4th lowest charge/summons ratio for child rapes of any area in England and Wales. In the 6 months between April-September 2018, West Yorkshire Police recorded 168 instances of sexual assault or rape of males aged 13 and over: equating to almost one rape or sexual assault per dayvi.

Recent events including the Jimmy Savile inquiries and similar investigations leading on from that have propelled sexual violence into the national consciousness. The current situation with regards to historical sexual abuse means that services anticipate a much higher volume of survivors coming forward over the next few years. The anticipated increase in service users will put an unprecedented strain on existing services – many of which are already at breaking point. Research commissioned by SWY recently found that services had been in greater demand in the wake of these events, with more people accessing services – but that there had been little increase in funding for services to enable them to keep up with

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demandvii. Even without the increase in demand, there is a desperate lack of funding across the third sector. A View from Inside the Box IV found that specialist sexual violence services were struggling as they were forced to compete for funding with larger ‘generic’ services. This is concerning as smaller specialist services closing through lack of funding will necessarily mean a decline in the quality of outcomes for sexual violence survivors across the country.

In this climate, an emerging pattern has been the diversification of women’s sexual violence services – services that had previously been women-only, but which have now begun to offer help to male survivors as well. This is problematic for a number of reasons: • It is a more attractive proposition for funders: combining men’s and women’s services would seem to make economic sense, so funders feel that these proposals will give them better value for money than gender-specific services – therefore combined services are more likely to receive funding • Women are less likely to access the service: research has shown that women are much more likely to seek help from sexual violence services that are a women-only space • Men are less likely to access the service: similarly, research has shown that men are more likely to seek help from sexual violence services that are specifically for men.

The current funding-driven trend for combined services is therefore not ideal for men or women, and is likely to result in fewer people overall reaching the services that they desperately need.

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Summary of results There was an unavoidable delay in starting service delivery due to the considerable technical challenges of the project, including the failure of the independently evaluated main platform supplier which meant a complex search for a new bespoke platform solution. Nonetheless, over the course of the pilot project, SWY has received 22 inward referrals. These referrals have come from a variety of sources (including GP referrals, local Victim Support and Rape Crisis services), but the majority of clients (16 out of 22 total) have been self-referred.

Of the 22 total referrals, at the time of the initial stage of the evaluation (December 2018), 6 had progressed to the stage of receiving virtual counselling (all of these clients had been self-referred). Each virtual counselling client had received between three and eight 60-minute counselling sessions using the project’s specialised virtual counselling system.

The evaluator used a combination of PHQ9 and IES-R scores & answers, and qualitative data from the counsellors involved, to analyse clients’ progress towards the project’s stated outcomes. All clients had completed the PHQ9 and IES-R at the time of their initial appointment, meaning that baseline measures were available for all clients. However, only 5 clients had completed more than one IES-R and only 3 had completed more than one PHQ9, meaning that tracked changes were only available for 83% and 50% of clients respectively. To address this weakness in the initial data set, an additional stage of evaluation was addended to this study in the form of an online survey during March 2019 (results at p.13 below).

To assess whether clients had been able to develop better coping skills, the evaluator picked out clients’ answers to one statement from the IES-R: ‘I tried not to think about it’. In this context, the evaluator sought a reduction in the score – taking a higher score (e.g. ‘Extremely’) to mean that clients were lacking in coping skills that enabled them to work through the issue or prevent thoughts arising in the first place. Of the 5 clients who had trackable answers, 3 (60%) evidenced a reduction.

To assess whether clients had been able to build resilience and self-confidence, the evaluator looked at clients’ answers to four statements from the IES-R: • ‘Any reminder brought back feelings about it’ – 4 of 5 clients (80%) saw a reduction, meaning counselling had had a positive effect • ‘Other things kept making me think about it’ – 3 of 5 clients (60%) saw a reduction, with one of these seeing a very significant reduction. Of the two clients who saw no change, one of these had marked this statement ‘Not at

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all’ from his initial assessment onwards, meaning this had not been a problem for him even prior to attending counselling • ‘I thought about it when I didn’t mean to’ – 2 of 5 clients (40%) saw a reduction • ‘Pictures about it popped into my mind’ – 2 of 5 clients (40%) saw a reduction The evaluator also looked at clients’ responses to one question from the PHQ9 as part of the assessment for this outcome – ‘[Over the past two weeks, I have been bothered by] feeling bad about [my]self – or that [I am] a failure or have let [my]self or [my] family down’. Of the 3 clients with trackable answers, 2 saw a reduction in the number of days they felt that this statement applied to them.

To obtain an overall quantitative score for this outcome, the scores for each of the above five clinical indicators were combined, giving a mean average 57% increase in resilience and self-confidence.

Counsellors’ session notes evidenced that 5 out of 6 clients (83%) had developed coping strategies as part of their counselling sessions, and noted that 100% of clients had built their resilience and self-confidence through attending sessions.

Observations included: “P… was very positive having had a good week, with him implementing some of the coping strategies we had discussed last week regarding his sleep, which seems to be helping… We reviewed and reflected on how he was doing and how he had changed within the manner as to how he is reacting to situations” “C was very open and discussed how he and his husband had experienced some conflict between them due to C not backing him on something C thought he was wrong about. C has struggled with the feeling that he was in the wrong and should have backed his husband up regardless, however C implemented the coping strategies he had learnt and communicated how he was feeling which has helped to resolve their situation and worked through things that had needed dealing with for a while. C is now looking to consolidate his progress and work on not beating himself up when he is making decisions that enhances his wellbeing.”

To assess whether clients had been able to seek out and take up opportunities which they have previously felt unable to do, the evaluator looked at counsellors’ session notes for all clients. 4 of 6 clients (67%) had notes which evidenced them seeking out and/or taking up new opportunities as a result of attending counselling sessions. Of the two who had not achieved this outcome, one had attended

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counselling for less than one month. Observations related to this outcome included: “[Following disappointment and feelings of despair after CPS decided not to take his case to court] P contacted Police and left a voicemail to detective dealing with the case. Police contacted P and after looking through the evidence again and possibly additional info P gave them, they are reconsidering this decision. P talked about the joy of being believed & how important this was for him.”

“S spoke about spending time with [his abuser] last week. Thinking about not wanting revenge, wanting some sort of relationship with him… Wanting to move on with his life. [S] noticed a shift in him[self]… being able to sit in a car alone with him. Being able bear him”

To assess whether clients were in a better position to work on overcoming the mental and physical ill-health and harmful behaviours that put their health at further risk, the evaluator assessed clients’ answers to three statements from the PHQ9: • ‘[Over the past two weeks, I have been bothered by] feeling down, depressed or hopeless’ – 3 of 3 clients (100%) saw a reduction in the number of days they felt this statement applied to them, with 2 of the 3 seeing a significant reduction • ‘[Over the past two weeks, I have been bothered by] trouble falling or staying asleep, or sleeping too much’ – 1 of 3 clients saw a reduction in the number of days they felt this statement applied to them. Of the two who saw no change, one had marked this marked this statement ‘Not at all’ from his initial assessment onwards, meaning this had not been a problem for him even prior to attending counselling • ‘[Over the past two weeks, I have been bothered by] poor appetite or overeating’ – 0 of 3 clients saw a reduction in the number of days they felt this applied to them These results suggest that the intervention has a significant positive effect on clients’ mental health, but at the present time has failed to support clients to put in place sufficient measures to enable them to overcome secondary health concerns. It is likely that this is simply due to the short span of time that most clients have spent engaging with the service – counsellors’ notes show that 5 of 6 clients have been working on strategies to e.g. improve sleeping habits, improve anger management strategies and develop assertiveness/self-confidence. However,

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100% of clients at the time of evaluation had evidenced improved mental health through attending counselling sessions. Observations include: “L… was quite upbeat and positive this evening. Although he had a couple of difficult days reflecting on our last session, he said he felt better for disclosing.

Shame & guilt were still the main feelings experienced by L so we talked at length on these difficult feelings… He is now sleeping better & for first time has had days without thinking of the abuse.”

“P…talked about the progress he had made. Although he was now implementing strategies to cope with his previous self-defeating behaviour, he felt that he now wanted to address the feelings he experiences when he recalls his historic abuse, which was mainly guilt and shame.” “[S] spoke about feeling happiness within about himself, feeling happiness in the core of his body… Noticed internal sadness reduced”

SWY also provided a report of counsellors’ feedback about the experience of using the virtual counselling system for themselves and their clients. This found that although many clients initially experienced technical difficulties, this tended to be quickly resolved and the overall experience was positive. Counsellors felt that most technical issues were due to their and clients’ unfamiliarity with the technology, and the report concluded that many of these could be avoided by enabling clients to try out the software in a dummy session prior to commencing their counselling.

The counsellors felt that the technology itself had significant benefits on a therapeutic level – the report noted that they ‘reflected that this medium supports a faster route into the trauma work around abuse. The clients seemingly felt more at ease in the settings in which the therapy was taking place and reflected this to the counsellors. Counsellors also reflected that clients were able to connect at a ‘safe’ distance and that discussions about abuse work were more direct and holistic in nature’. This suggests that the premise of this pilot – that a secure, online counselling service will reach male survivors who are unwilling to engage with traditional services, and will have great benefits for them – is correct, and the project has been a success in this regard.

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Online Survey To assess progression on the above outcomes and compare counsellor impression with service user experience, further measurements were taken in March 2019 in a follow-up online survey. Five respondents were asked to assess which, if any, of a range of coping skills they had developed as a result of the counselling service.

4 of the 5 respondents (80%) attributed the development of new coping skills to their attendance of virtual counselling, meaning counselling has a positive effect.

Of the 4 practicing new mechanisms for emotional management: 80% had begun practicing mindfulness, 40% now utilised breathing exercises, 20% had taken up physical exercise, 20% meditation, and 20% employed distraction techniques. The uptake of a range of new coping skills among the respondents illustrates the ethos of tailored and personal support aspired to by Ben’s Place.

Respondents were asked to assess whether since attending counselling they felt more confident. All respondents reported in the top 2 tiers of 5 increments scale: 60% (3) answered ‘yes, very’ and 40% (2) reported ‘a little’. When asked the same of their resilience, 60% (3) answered ‘yes, very’ and 40% (2) ‘a little’. Indicators of these reported changes included: 100% (5) of respondents reporting that they now felt able to talk to their partner, family or friends about their experience of sexual violence; 100% feeling like they were ‘doing the right thing’ for themselves; 100% reporting that on average they now have ‘more good mental health days than bad’; 40% (2) reporting that they had stood up for themselves in a disagreement at work or at home; and 40% (2) able to ‘get on with [their] day’ when ‘something bad happened’. These evidence the variety of ways in which service users observe tangible positive impact of the virtual counselling service upon both their confidence and their resilience.

To determine increase in uptake of opportunities and client outlook on this, respondents were asked whether since attending counselling, they felt more able to take up opportunities to improve their lives. 60% (3) responded ‘yes, very’, 20% (1) answered ‘a little’, and 20% (1) were ‘unsure’. Follow up questions sought indicators of these changes. For instance, 60% (3) of respondents reported feeling motivated to ‘change [their] lives for the better’. 40% (2) had applied for either a new job or a new training course, and 20% (1) had felt able to go somewhere they had never been before.

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To examine the extent to which clients were now in a better position to work on overcoming mental and physical ill-health, survey respondents were asked how they would rate their mental and physical health a) when they first started counselling, and b) at the time of asking in March 2019 (having each attended 10+ counselling sessions). At the start of counselling, 20% (1) reported their mental health to be ‘very bad’, 40% (2) ‘bad’, 20% (1) ‘neutral’, and 20% (1) ‘good’.

Whereas, following 10+ sessions, 80% of respondents (4) reported ‘good’ mental health, and 20% (1) ‘very good’. These results suggest that the counselling services have a significant positive effect on clients’ mental health. Similarly, reports of physical health prior to counselling improved from 40% (2) ‘bad’ and 40% ‘neutral’, to 40% (2) ‘good’ and 60% ‘neutral’. This demonstrates a greater increase in physical health than had previously been reported, concurring with the evaluator’s previously stated hypothesis that physical health improvement may well increase according to clients’ time spent in the programme.

Client Comments

‘Just perfect, really helping me in coping strategies and rewiring my thoughts’

‘I am very happy I contacted Ben’s place, it has made a big difference to me.

Please keep it up.’

‘My counsellor is perfect and she makes me feel very comfortable’

‘I would just like to say thank you’

‘Wonderful service which helped me start my journey to recovery’

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Case study ‘P’ self-referred to Ben’s Place following encouragement from a local Rape Crisis Centre where he had spent a long time on the waiting list. In his initial assessment he explained how he had been a victim of sexual abuse as a child. P’s test scores on the PHQ9 and IES-R revealed that at the time of his initial appointment, he was suffering from moderately severe depression and severe post-traumatic stress. P was unemployed, reported having difficulties sleeping, and had been having thoughts of self-harm and suicide.

P’s initial counselling session showed that he was feeling moderate anxiety about mundane events – for example, he was struggling with feelings of anxiety about an upcoming holiday with his wife and daughter. P’s counsellor worked with him to explore these feelings and discussed options for reducing his anxiety which would be acceptable to all parties concerned. At the next session, P demonstrated that he had put some of these strategies in place and had come to an arrangement that felt like a reasonable compromise to all involved.

Over the course of the next few sessions, with his counsellor’s help P was able to explore some of the ways in which his historical abuse had affected him – in particular, unpacking his reaction to conflict. P’s counsellor suggested some coping strategies which P was keen to set in motion.

Following P’s dedication in implementing his counsellor’s suggested coping strategies, P revealed that he had felt able to apply for some part-time jobs and now had an interview coming up. P’s counsellor worked with him to develop some coping strategies regarding his difficulties sleeping, as P perceived that this could be a barrier when it came to employment. At the following session, P was very positive – he had been using these coping strategies and had seen some improvement in his sleeping habits. He also disclosed that his job interview had been successful and he would be having an induction into his new job that week.

Although P’s PHQ9 scores stayed largely constant (indicating that his baseline depressive symptoms were maintaining), he showed a dramatic improvement in one area – while at the beginning of his engagement with the service, P had consistently reported having ‘several days’ out of the preceding 2 weeks where he had had thoughts of self-harm or suicide, this had reduced to zero days with these thoughts after 4 sessions. P’s IES-R scores showed even greater improvement – from a baseline score of 36 (indicating likely PTSD), he had reduced this to 21 by session 6. In real terms, this represents a huge improvement in P’s ability to cope with challenges in his life – borne out by the impressive progress outlined above.

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Recommendations and further work While the PHQ9 and IES-R are excellent tools to track client progress from a clinical perspective, the data produced is not easily analysable for project and grant management purposes. It is recommended that SWY considers adding outcomesfocused data collection methods (e.g 6-monthly survey of 3 scored questions) to track client progress towards the overarching project outcomes for future work.

Ideally, to maximise client take-up and quality of data, these would be administered by counsellors directly to the client. In addition to this, it may be helpful for SWY to explore ways to increase client engagement with PHQ9 and IES-R to improve their monitoring capabilities for clinical outcomes – for example it may be that the automated emails are a barrier for some; it may improve engagement if counsellors discuss it during sessions.

While recognising the inherent challenges in a process which is necessarily to some extent in the control of the prospective client, it is recommended that SWY explore if there are any ways to speed up the process for inward referrals so that they are entered into the system and can begin the process of engaging with counselling.

It is clear that self-referrals are not only the most popular route into the service, but that clients who self-refer are more likely to take up and persist with the process of counselling. SWY’s excellent website has been a great success in enabling clients to self-refer (web traffic during the period covered by this pilot was 75% higher than the year before – 3886 individual users in 2018 compared with 2217 in 2017). It is recommended that the website continue to be maintained and promoted as widely as possible.

The pilot has highlighted that the light-touch support SWY has historically offered (e.g. signposting, text and telephone support) is effective at reaching a large number of beneficiaries. This complements the support offered through this project, which due to its more intensive nature will necessarily reach a lower number of beneficiaries. Going forward, SWY should recognise this when reviewing service delivery for the virtual counselling service.

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Reviews of client experience of the virtual counselling service demonstrate the value of this service to SWY users. It is clear that the virtual counselling service has made marked improvements in service users’ self-confidence, resilience, coping skills, capacity to seek out and take up new opportunities, and ability to overcome mental and physical ill-health. Evaluators recommend that SWY should continue the provision of this vital service.

The increased improvements experienced by the clients who had had more sustained contact with the service, measured via the follow-up survey in March 2019, suggest that it is important to identify and implement procedures that encourage engagement to be continued for the assumed average of 20 hours.

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Appendices Appendix I – Patient Health Questionnaire (PHQ-9) Over the last two weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things? [Not at all/Several days/More than half the days/Nearly every day] Feeling down, depressed, or hopeless? [Not at all/Several days/More than half the days/Nearly every day] Trouble falling or staying asleep, or sleeping too much? [Not at all/Several days/More than half the days/Nearly every day] Feeling tired or having little energy? [Not at all/Several days/More than half the days/Nearly every day] Poor appetite or overeating? [Not at all/Several days/More than half the days/Nearly every day] Feeling bad about yourself – or that you are a failure or have let yourself or your family down?

[Not at all/Several days/More than half the days/Nearly every day] Trouble concentrating on things, such as reading the newspaper or watching television? [Not at all/Several days/More than half the days/Nearly every day] Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual? [Not at all/Several days/More than half the days/Nearly every day] Thoughts that you would be better off dead, or of hurting yourself in some way? [Not at all/Several days/More than half the days/Nearly every day] Total = __/27 Depression Severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe.

Appendix II – Impacts of Events Scale – Revised (IES-R) Please select the answer which most closely relates to how you felt: Not at all/A little bit/Moderately/Quite a bit/Extremely Any reminder brought back feelings about it

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I had trouble staying asleep Other things kept making me think about it I felt irritable and angry I avoided letting myself get upset when I thought about it or was reminded about it I thought about it when I didn’t mean to I felt as if it hadn’t happened or wasn’t real I stayed away from reminders about it Pictures about it popped into my mind I was jumpy and easily startled I tried not to think about it

Appendix III – 1. What is your age?

2. How did you find out about Ben’s Place virtual counselling service?

• Referred from GP • Referred from other service (e.g. Rape Crisis) • Self-referred: previous knowledge of Survivors West Yorkshire • Self-referred: found info from Ben’s Place leaflet/poster • Self-referred: own internet research • Other – please specify: 3. How many sessions of virtual counselling have you completed?

4. Have you developed any new coping skills through attending virtual counselling? If so – can you name any specific new coping skills you developed? (Please tick all that apply) • Breathing exercises • Mindfulness • Visualisations • Mantras • Distractions (e.g. go for a drive, watch TV, read a book) • Physical exercise • Meditation • Other – please specify: • Not applicable – I did not develop any new coping strategies 5. After attending counselling, do you feel that you are: • More confident? [Yes – very/Yes – a little/No/Not sure]

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More resilient (i.e. better able to cope when negative things happen in your life)?

[Yes – very/Yes – a little/No/Not sure] More able to take up opportunities (e.g. a new job or training course) to improve your life? [Yes – very/Yes – a little/No/Not sure]

6. Thinking back to when you first started virtual counselling – how would you rate your: • Mental health? [Very bad/Bad/Neither bad nor good/Good/Very good] • Physical health? [Very bad/Bad/Neither bad nor good/Good/Very good] 7. Thinking about yourself now after attending virtual counselling – how would you rate your: • Mental health? [Very bad/Bad/Neither bad nor good/Good/Very good] • Physical health? [Very bad/Bad/Neither bad nor good/Good/Very good] 8. Have you experienced any of the following as a result of attending virtual counselling (tick all that apply)?

• I stood up for myself in a disagreement at work or at home • I made new friends • I felt able to talk to my partner/family/friends about my experience of sexual violence • I felt like I was doing the right thing for myself • I felt able to spend time in the same place as the person who abused me • On average, I had more good mental health days than bad • When something bad happened, I felt able to get on with my day • I felt motivated to change my life for the better • I applied for a new job • I applied for a new training course • I felt able to go somewhere I had never been before (e.g. going on holiday, attending a new gym, starting a new class) • Other positive outcome (please specify) 9. Do you have any other comments about Ben’s Place virtual counselling?

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References Moor, A. & Farchi, M. (2011) Is rape-related self blame distinct from other post traumatic attributions of blame? A comparison of severity and implications for treatment., Women & Therapy 34(4):447-460 ii Combat Stress (2018) Exploring the feasibility and acceptability of using tele- therapy for UK veterans with PTSD., UK: Combat Stress. iii ONS (2017) Bulletin Tables - Focus on violent crime and sexual offences (year ending March 2016), UK: Office for National Statistics iv Bellis, M. & Ashton, K. (2016) Adverse Childhood Experiences (ACEs) and their association with health-harming behaviours in the Welsh adult population., UK: Public Health Wales NHS Trust v O’Leary, P. & Gould, N. (2008) Men Who Were Sexually Abused in Childhood and Subsequent Suicidal Ideation: Community Comparison, Explanations & Practice Implications., The British Journal of Social Work, 39(5):950–968 vi Unpublished statistics from West Yorkshire Police vii Scurlock-Evans, L. and Mahoney, B. (2016) A View from Inside the Box IV: Connecting the Boxes: Coming Home., UK: Survivors West Yorkshire i