Sexual Trauma Sexual Trauma Program Transcript [MUSIC PLAYING] FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. FEMALE SPEAKER: I was. ALL: I was. FEMALE SPEAKER: A woman is sexually assaulted every 2 and 1/2 minutes. Call 800-656-HOPE. NARRATOR: In this program, Linda Kelly shares her experiences as a responder to victims of sexual assault and partner violence. She also describes potential barriers victims might face when seeking help. LINDA KELLY: Victims of sexual assault are much more likely to suffer from a variety of mental illnesses after an assault. For instance, they are three times © 2018 Laureate Education, Inc. 1 Sexual Trauma more likely to suffer from depression. They're six times more likely to suffer from post-traumatic stress disorder. And they are 26 times more likely to use drugs and 34 times more likely to use alcohol or abuse alcohol. They are also more likely to contemplate suicide, usually four times more likely are the national statistics. And often, these effects aren't seen immediately after the assault. So it's very difficult to predict. It's very important for them to get into counseling as soon as they are able to. When a patient comes in to the emergency department and a SAFE examination is requested by law enforcement, the SAFE nurse will begin that process with an interview. The first thing that we want to do is, obviously, sit down and establish a rapport with the patient, assess her emotional state at that point in time to give us an indication of how we can best interact with her. I've had some patients who are so traumatized they're kind of curled up on the floor in the corner of the room. I have other patients who, before I take the picture of their face, want to make sure their hair is in place and am I smiling. That's not an indication of whether an assault occurred. It's just how they're responding to the situation and the trauma that they've experienced. That only helps me figure out how to interact with that patient. Once I do that real quick assessment, sit down and talk with the patient. What happened? Tell me the details of what happened. Do you think you may have scratched the perpetrator while you were resisting? All of those things are clues for me to help guide my examination once we begin that actual examination process. I will ask her what kind of sexual act occurred and the various types of sexual acts and whether a barrier method was used. Again, that will guide me and figuring out where I might have potential forensic evidence, vaginal, anal, or someplace on her body. Once I've finished that part, I will obtain some blood and urine specimens from her and have a physician in the emergency department examine the patient to make sure that she's medically stable for me to begin my process. We are fortunate in our program that we have a dedicated private suite of rooms that are outside of the emergency department. And it allows us to conduct our examination in relative quiet and peaceful surroundings. It is a very stressful process for the patient to undergo a SAFE exam. And we have found that this has just aided enormously in helping us go through that process as expeditiously and sensitively as possible for the patient. © 2018 Laureate Education, Inc. 2 Sexual Trauma At that point, once I complete the exam, I use a-- typically it's called-- a rape kit around the United States. The kit includes various envelopes, smaller envelopes, which are indicative of specific tests that would be conducted. So, for example, when I ask the patient, did I think she scratched the perpetrator during the assault, the reason I'm asking that is that, if she did, I would use the fingernail scraping kit and scrape under her fingernails over a piece of paper. And any material that might be under her fingernails would fall onto the paper. Carefully fold that up. And that gets sent to the crime lab for their analysis. Also, if she indicated there was any other body fluids from kissing or biting or any kind of injuries like that, I would probably do a wet to dry swab of that area and also submit those swabs to the crime lab for analysis. After we get finished-- all of those envelopes in the kit-- we provide antibiotic prophylaxis to hopefully prevent transmission of an STI. It's not 100%. And we also, of course, recommend follow-up for the patient with their personal physician if there any symptoms of an STI after this assault. We have also, during the course of that blood work, tested for a preexisting pregnancy. And once I have those results, I, if negative, offer her emergency contraception, which is about 98%, 99% effective in preventing pregnancy. That emergency contraception is known as Plan B. Forensic examinations are reimbursed to the hospital by, in the case of Maryland, the Department of Health and Mental Hygiene, the State of Maryland, if you will. And all of the locations throughout the United States have that kind of a setup. The monies actually are generated from a federal program to the state. There's a National Protocol that was established in, I believe, it was, the late 1980s that laid out what best practice would be for providing services for victims of sexual assault in the United States. And most of the SAFE programs nationally have tried to adopt the criteria of those best practices. And so incorporated in that was federal money to help initiate SAFE programs in jurisdictions. Because in the very early days, before there were SAFE programs, if a woman presented for reporting a sexual assault, she would come to any emergency room. And typically, the emergency room is very busy and crowded as they are now. The person who would be called to come and complete that kit might be the newest resident or intern. And I have heard one of the physicians that I know say, I can remember doing those kits and getting called in the middle of the night, because that's usually when this happens, and reading the directions as to how to complete the kit as he proceeded through the exam. © 2018 Laureate Education, Inc. 3 Sexual Trauma Clearly, for women who are suffering that kind of trauma, that was not an ideal situation. So SAFE programs today, using the National Protocol, we've made wonderful advances and, as I said with our program, fortunate to have a dedicated suite, including a private shower. Patients can shower. We have toiletries and clothing for them that they can take home with them. It's a much, much different atmosphere than typically it had been in years past. A sexual assault response team is actually part of the recommendation of the National Protocol, commonly referred to as a SART, S-A-R-T. It is comprised of the principals who are involved in sexual assault investigation, prosecution, and treatment. So essentially, all of the parties who are involved and interested in providing sexual assault services for each jurisdiction get together. And the purpose is to meet regularly, first of all define the scope of the program that you're going to establish. And there's a whole implementation process that can be followed. Once you're operational as we are, now, we meet and we talk about how services have been provided. Have we encountered any barriers to providing best practice services for victims? Did we have any missteps since the last meeting? We try to challenge ourselves with looking for ways to improve services. The SART team for Baltimore County was instrumental in helping the SAFE program determine that we needed to have dedicated private space. And they also helped in the design of that space, worked with us, the SAFE nurses, and the hospital administration to ensure patient privacy and make sure that this new space would be created with a victim-centered approach. The other thing that recently happened, which I think is very remarkable, is we had a SART meeting in Baltimore County. And we're fortunate in Baltimore County that the police officers and the State's Attorneys in this jurisdiction are currently working cold rape cases. When the officers made first contact with victims of these cold case rapes, they were finding a variety of emotional responses. What concerned them most were the victims who became emotionally distraught. There was one victim who refused to leave her home. All of these years, she had become reclusive, kept the shades down. And she had apparently never truly dealt or resolved those issues from her rape. And so now with the officers approaching her, she really decompensated. And they were very concerned about her. So they came to the SART with that example in mind as a worst-case scenario and said, isn't there something that we can provide these victims to help them through this terrible time? Also, we want to make sure we have a successful prosecution of the suspect. © 2018 Laureate Education, Inc. 4 Sexual Trauma The psychologist on our SART, Dr. McKenna from Towson University, offered to develop some materials for these victims. And as a result, the police department, the State's Attorney, Towson University, and GBMC collaborated to produce a brochure. We titled it Cold Cases: Time May Not Heal All Wounds. And essentially, it is describing, for these victims, what kinds of emotional responses they may begin to be feeling at this point in time and that it's normal for them to feel this range of emotions, and then some of the things they can do to help get through this process, certainly counseling and, if they haven't already been involved with a counselor, give them suggestions about that process. Intimate partner violence and domestic violence are some of the most challenging patients that SAFE nurses, physicians, and law enforcement officers work with when there is an assault. Patients that are in these emotional situations with a partner who is abusive have many, many obstacles that they perceive and that are reality for them in order for them to get the appropriate treatment and make some very hard decisions about getting them into a safe place. And so when we see patients in the emergency department, it's obviously in a very acute setting. Some sort of traumatic incident has occurred. Typically, our ability to really help that patient for a long-term process is extremely limited if nonexistent. That's why referral is so important that we try to encourage them to avail themselves of counseling services that are available through rape crisis or domestic violence facilities. And I can think of one case, one patient, that I had that I allowed myself to become a little bit more involved. It was a domestic violence situation. And this patient was, I think, about 37 years old. We'll call her Mary. And Mary came in. She had multiple bruises and contusions. She had been raped by her spouse who was also the father of her three children. Two were elementary school age. And one was a teenager who was off on his own and had some other issues of his own. This young lady, it was about 3:00 in the morning, and I had finished my exam of her. I had heard the whole story of what happened. This was not the first time that her husband had abused her. And clearly, with her description, every scenario was getting more and more violent. In addition, this young lady-- who had a beautiful face, I remember telling her that-- she had, clearly, other physical the problems going on. And I felt very concerned for her, that she needed to get medical treatment for herself not related to this assault. © 2018 Laureate Education, Inc. 5 Sexual Trauma She had some alcohol problems. And I felt that, probably, the alcohol was, at this point, already in her young life, creating some medical problems for her. So what happened with her, her husband was in jail, locked up for this assault. For some reason, I felt that with her there was a connection, that maybe this was the opportunity for her to focus on herself and taking the time to get herself well for her and for her children. He was going to remain in jail for a period of time while this trial would be going on. But he also had some other charges, which were apparently pending. So let's take this time and figure out how to help you get well. She was just so open to that idea. I just felt such a connection. Maybe this was the one person that I could help. And so I kept in touch with her. We discharged her that night. The police officer ensured that she got home with her children. I wanted her to make sure she followed up to get some blood work done that her physician had ordered. I wanted her to get to counseling at a rape crisis facility that works with us. And so I told her I'd call her in a couple of days. When I called her, she was sober, which was a wonderful thing. And she had gone through some withdrawal, did not feel she needed to come back to the hospital for that. She was taking care of her children. However, the very real problems that she had was she had no money, no source of income. The breadwinner was now in jail. And she had no gas in her car. So the logistical problems were how do I get to the lab to get my blood tests? How do I get across town to the rape crisis facility to initiate counseling? We got her some emergency funds from yet another hospital that provided her with gift cards that allowed her to get gas in her car, go get her lab tests, get some groceries. I made a connection with another organization that sent someone to her home to do the paperwork that would process Social Services funds for her. I mean, all of those pieces, you know. And she took each step. She kept going. She was staying sober. I was so hopeful for her. But each one of those steps was a huge challenge, because there's not a system that takes someone in this situation and carries them through it. It was very challenging to try to pull those pieces together for her and to keep her uplifted through that time. I stayed in touch with her. She would call my cell phone occasionally and let me know she was doing OK or what she was having a problem with. And the next time I saw Mary was in our emergency department. I just happened to be there one night and saw her name on the board and went out to the waiting area. © 2018 Laureate Education, Inc. 6 Sexual Trauma And she had obviously been in some sort of physical altercation. She was intoxicated, tearful. She was with a neighbor. And she was alleging that she had been raped by a stranger. And we went in and sat together in one of the ER rooms. And I encouraged her to tell me what's been going on. Essentially what happened with Mary was she took all of those first steps that we were laying out for her, overcoming the alcoholism without having the support, the counseling, Alcoholics Anonymous, a 12-step program, whatever it was that would work for her. She just had too many obstacles in her way. So she resorted to alcohol again. And then, once again, that led her down a path to making some bad decisions, excessive use of alcohol and, in this case, something happened. She had no real memory of what happened. And it turned out that she recanted her initial charge that someone had raped her. And while we were sitting on the stretcher, she said to me, her husband was still in jail. The trial had not come up yet. And she said, you know, I'm withdrawing the charges against him. And I said, no, I didn't know that. And she looked away from me. And she was very tearful. And frankly, I was on the verge. And I was holding her hand. And I said, why Mary? Why are you feeling that that's necessary? And she said, I have no choice. And she said, how can I survive with my children? I'm about to be evicted because I can't pay my rent. In fact, her landlord was even trying to accost her, because he knew she was so vulnerable. And she started to cry. I said, do you feel like you're backed into a corner, that you see no possibility for your survival and the survival for your children without him? And she said, absolutely. Domestic violence and women who are in that situation, particularly if they have children, they are very, very limited in what they see as the scope of possibilities for them. They have to figure out how to survive with their children. And if they lock up Daddy, the breadwinner, well, how do you keep your home? How do your children go to school? Very real problems. And it's usually not until they see something beginning to harm the child-perhaps the child is starting to respond physically to the abuse that they're witnessing of the mother. Or perhaps the abuser begins to abuse the child-- and once the mother sees that, the mother, in my experience, will do everything to take those children and run. And there are some resources at that point for domestic violence shelters and people that will be there as a resource. But they have to give up everything in order to get to that point. © 2018 Laureate Education, Inc. 7 Sexual Trauma [MUSIC PLAYING] Sexual Trauma Additional Content Attribution MUSIC: Creative Support Services Los Angeles, CA Dimension Sound Effects Library Newnan, GA Narrator Tracks Music Library Stevens Point, WI Signature Music, Inc Chesterton, IN Studio Cutz Music Library Carrollton, TX Special Thanks: Fairland Center/Region One Mental Health © 2018 Laureate Education, Inc. 8 1 Case Conceptualization Form Counselor’s Name: Date: I. Assessment Discuss background characteristics, presenting complaints, history of the problem, and social and cultural considerations. Describe the differential diagnosis, including any related diagnoses that were considered and ruled out. Explain the legal and ethical considerations that are relevant to the client situation. II. Case Conceptualization Use your theoretical orientation to provide a concise summation of the client’s psychological strengths and difficulties. Integrate your client’s history with the theoretical orientation you have selected to support your explanation. III. Treatment Plan List two long-term treatment goals for client issues with at least two short-term objectives that are steps in how you plan to meet each goal. The objectives need to be specific and measurable and are driven by your theoretical orientation and the element you are asking the client to change (e.g., thoughts, feelings, actions, etc.) Problem, Issue, Challenge, Obstacle, Symptom: Treatment Goal 1: Objective: Objective: Problem, Issue, Challenge, Obstacle, Symptom: Treatment Goal 2: Objective: Objective: IV. Interventions Discuss how you will work toward the treatment plan goals. Base your interventions on the theoretical orientation you discussed in your case conceptualization. Be sure to use evidence-based practices that are supported by your research. Describe any referrals that you believe will be beneficial. Jamie, Maria, and Sofia Luna You are working at an outpatient clinic when a family is referred to you for an intake session. Last night, the police were called to the Luna household for a domestic disturbance. Since the family is working on the immigration process to become American citizens, their case worker recommended that they seek counseling to address the family issues. Jamie is 28 years old and speaks moderate English. He grew up in Honduras with his parents, eight brothers and sisters, and grandparents. His father frequently went on “drinking binges” and would “put his mom in her place.” It was a patriarchy system in which they did not have a lot of income and his father had numerous mistresses. He reports that he was raised with a strong Catholic background, and he continues to practice today. His uncle sexually abused him from ages 6 to 13 when Jamie reports he was able to beat him up enough to get away. He did not want to appear “gay,” so he had numerous sexual partners and got in lots of fights to prove his masculinity. In his late teens, his brother got involved with the Mara Salvatrucha gang and tried to recruit Jamie. This was around the time he met Maria, and they decided to illegally enter the States at Maria’s urging since she was pregnant and wanted to raise their child in a better life. Maria is 26 years old and speaks little English. She grew up in Honduras as well with her mother, grandmother, and nine brothers and sisters. She never knew her father who abandoned the family when she was an infant. Her mother had several other long-term relationships but never married. Her family was “very poor” and she did not finish school past fifth grade. Maria was raped when she was 10 and then began a life of prostitution to help her mom with feeding the rest of the family. She met Jamie when she was 18 and quickly got pregnant. She illegally entered the States and began to work in a home in Texas. After she had the baby, Jamie was able to illegally enter the States and began working odd construction jobs to pay their bills since Maria no longer was working to care for Sofia. Jamie and Maria report that they have not been successful in having any more children, which Jamie blames on Maria’s previous sexual history. He is ashamed since in his culture, “men are supposed to have many children.” Maria reports that she had many difficulties in having Sofia and did not get the proper medical care she needed. Sofia was born premature and has speech and other motor skill delays. Both Jamie and Maria admit they used drugs in the past but adamantly deny any current drug use because they know it would affect their immigration status. The police found drug paraphernalia in the household, but Jamie and Maria stay in a condo with two other families and reported the material was not their own even though Jamie appeared intoxicated and smelled of marijuana when the police arrived last night. They both admit that when they get angry with each other, they hit and punch each other. Maria says that she will not be kept in a system like the one in which she was raised in Honduras where she is supposed to be subordinate and just take whatever Jamie gives her. She accuses him of having affairs and sleeping around with everyone. They report that they have arguments at least two to three times a week and have separated several times to get away from each other. Maria says that she is dependent on him since she is not working, and he needs to step up and be a man to take care of his family. Maria says that on the night of the police incident, she caught him with another woman at the corner store, and when he got home, she threw a pot at him. They fought, and at one point, he grabbed a knife and threatened to cut her if she did not calm down. Sofia witnessed all of this and saw both of her parents put in handcuffs in the front yard. Sofia is 8 years old. She is very shy but speaks English well. She is in the second grade and was held back in kindergarten due to her developmental delays. She is currently at risk of being held back again, and her attendance record is very poor. She reports that she hates to see her mom and dad fight all the time. She gets very scared, has trouble sleeping, and hides in her closet. She does not have many friends because the kids “pick on me for being dirty and a ‘spic.’” She mentions that one of the other male children living in the condo does come to “comfort her” at night and gives her “lots of hugs and squeezes.” Maria reports that she has caught Sofia “rubbing her private parts” on the couch arm and trying to kiss all the other little boys in the house. She denies that Sofia has been sexually abused and blames it all on Sofia. After completing the intake on the family, your supervisor tells you that you can decide which person in the family system you want to focus on for individual counseling sessions—Jamie, Marie, or Sofia—with the understanding that the other family members will work with your colleagues with possible joint family sessions in the future. For the assignment, select one member of the family to complete your case conceptualization, understanding that this family member is a part of the overall family system.
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