proposed vision for services
Vision for mainstream early intervention and crisis support service:
Nation-wide coverage of specialist sexual violence support services which are able to provide 24/7 early intervention following recent sexual assault and on-going acute interventions when needed to maintain or assist in establishing emotional and psychological well-being of survivors.
The vision above has not changed since the 2009 guidelines project, and many of the components remain the same. However, there is also significant difference resulting from the engagement with a number of groups in the “inclusion” projects and developments in services overseas. For this reason, the critical components of service are presented as “proposed”, as full consultation about the changes needs to occur with the sector.
Proposed Critical Components of Service
1. Partnership with a kaupapa Maori Service provider responding to sexual violence
Maori are at higher than average risk of sexual violence, and can present with complex difficulties related to the impacts of colonization and cultural identity. Currently, there are few kaupapa Maori services specialising in sexual violence left across the country, and none with 24/7 capacity, so the ways that the partnerships would operate in terms of service delivery would change over time with the development of further kaupapa Maori services.
2. Capacity to provide inclusive services
This will include national and/or local relationships with groups who serve or are advocates for populations with particular cultural or other needs. These will vary depending on local need and capacity. All of the groups involved in this research recommend that relationships are built and cultural knowledge is developed to enable services to provide inclusive services. Further recommendations from many groups are that staff is recruited from the specific cultural group.
3. 24/7 telephone and internet communication service
- Acute counselling interventions e.g. safety assessments
- For survivors and their support networks
- Consultations for other service providers
- Liaise with police and medical teams re call-outs
- Co-ordinated data collection
Provides access to specialist services for much of the population. Easy to access – doesn’t require travel, can often be accessed without needing to explain to someone else where you are going. Can respond to acute need, and work with the caller to resolution or make emergency referrals. Internet capacity meets the needs of young people – it meets them where they are and in a manner which is comfortable for them.
USA - Monroe et al (2005). In a state wide evaluation of services provided by specialist sexual assault centres in Maryland, USA – 89.9% of respondents said they were satisfied or very satisfied with hotline service.
USA - Wasco et al (2004). In a state wide evaluation of sexual assault services in Illinois, of those service users who agreed to participate in the evaluation, more than 80% of hotline callers said that they gained somewhat or a lot more information, around 90% said that they felt some or a lot of support had been provided to them.
NZ – Woodley at al (2013). In this research with young people of different ethnic groups, most said that an online service would help them to access information and assistance. Barriers remained for those who said that their internet use was monitored.
4. 24/7 Call-out service for advocacy and support
- (ideally 2 staff available for each call-out, 1 for survivor, 1 for whanau)
- Police interviews – from preliminary interviewto closure of case
- Forensic medical examinations
- Therapeutic medical examinations
- Follow-up medical examinations when requested
Police and medical processes can cause further traumatisation through replication of dynamics of the abuse or triggers into fear endured during the abuse. Police and medical staff have other roles to perform so cannot always maintain focus on the psychological well-being of the survivor. Support can offset the development of PTSD and other adverse impacts.
The police inquiries were beginning to come together, and providing them with the help they needed was traumatic in itself, especially when they asked for specific details of the attack. Sessions with the counsellor gave me the space to off- load the added emotional stress.
(Leefman, 2005, p. 52).
4a. Importance of someone to advocate for survivor well-being:
Kylie was “raped at knifepoint by a stranger in an attack which included her being forced to drink alcohol and being beaten around the head”. She was accused of making a false complaint due to inconsistencies in her story. From her point of view, this arose from being pushed to provide information when she was “past it”, no longer able to think straight.
I did feel they were calling the shots. I was too tired and distressed to think that I had a right to say, “This is enough”.... It didn’t really occur to me that I could say I was too tired and wanted to go home. (Jordan, 1998, p. 42)
4b. Importance of assistance from someone who understands the process:
Then an officer came in to say that they were trying to find a woman doctor to examine me. He had assumed that I would prefer a woman. I didn’t tell him that I really didn’t care; I thought his sensitivity was too nice to throw away. And when I finally had the medical examination later that day, I was pleased I hadn’t said anything. The examination was far more extensive than I would ever have imagined; I could not have coped if the doctor had been male. (Leefman, 2005, p. 31).
I was beginning to understand that this thing – rape – was far more taxing, far more demanding, than I had ever imagined. I thought I was strong enough to overcome its effects. I thought I could keep living the way I’d always lived...... At first I had refused to allow the attack to change my life, but now I realised that it was a greater force than I’d reckoned with. (Leefman, 2005, p.53)
Ideally need two staff to work with family:
Telling mother: Immediately she was in tears. I put my arms around her to comfort her, knowing that I didn’t have the strength for this. Fortunately she had a good neighbour who came in to take care of her. My trauma was different from hers, and each of us needed support. (Leefman, 2005, p. 49).
NZ – Jordan (1998) - Identified four themes of what women need to be satisfied with police performance in their experiences in reporting process:
To be believed
To be treated with respect and understanding
To be allowed to retain some degree of control over proceedings; and
To be provided with adequate information. (p.70)
These themes form the basis of much of the advocacy work crisis support workers do in police and medical processes.
USA – Campbell (1998) – Contact with medical and legal systems can lead to higher levels of post-traumatic stress following rape. This effect can be ameliorated with mental health support.
USA – Campbell (2006). Rape advocates assist victims/survivors to get a better deal in medical and legal systems and to feel less distressed by them.
USA- Wasco et al (2004) State wide evaluation of Illinois sexual assault advocacy services (what we would consider call-outs to police interviews, medical exams and court support). Of those who participated in the evaluation, 87.2 % reported that they got somewhat or a lot more information, 96.5% some or a lot of support, and 84.7% reported somewhat or a lot of help in making decisions.
UK- Lovett, Regan & Kelly (2004) – 93% of survivor/respondents were satisfied with crisis worker role at medical examinations. This was the highest score for any of the services provided by the Sexual Assault Referral Centre. Both survivors and police supported the role of the support worker at the police interview. Survivors said that she helped them to feel safe and relaxed, and police commented that it assisted the survivor to stay the distance through a difficult process, and it allowed them to concentrate on their own role. Statistics also showed a relationship between the crisis support worker being involved and survivors withdrawing from the legal process – of those who did not have a crisis support worker, 53% withdrew, of those who did, only 20% withdrew.
Petrak (2002) identifies a number of factors indicating need for assessment in the acute post-rape period:
a history of suicidal behaviour is associated with the presence of suicidal ideation post-rape. (Petrak & Campbell, 1999, cited in Petrak).
a prior history of sexual assault leads to more severe signs of traumatisation post-rape (Ruch, Amedeo, Leon, & Gartrell, 1991, cited in Petrak).
Alcohol and drug abuse relates to increased PTSD symptomatology (Ruch & Leon, 1983, cited in Petrak).
Stressful life events in previous 12 months may increase post-rape symptomology, though this hasn’t been confirmed by all studies – (Ruch & Leon, cited in Petrak).
Zoellner, Foa, & Brigidi (1999, cited in Petrak) Found that positive social support might offset the development of PTSD following rape.
5. Emergency face to face sessions – day-time
- To assist clients with emotional and functional stabilisation, assessing and arranging safety, and decision-making.
Acute counselling interventions
Assistance with decision-making
Arranging access to resources
For survivors and their support networks
Most clients presenting for this service feel that they are in “crisis”. They need to be responded to as soon as possible so that distress can be contained, time-dependant decisions made, and plans for safety put in place, Responding appropriately to acute need reduces long-term impacts. Many situations can lead to acute need arising, for example, a recent trigger to memories of sexual assault, recent life stressors combining to render useless prior strategies of ignoring the impacts of the sexual assault, imminent change in possible exposure to the offender (e.g. up for probation), birth of a child, another family disclosure, or an upcoming court case. One of the most common causes of acute need is a recent sexual assault. Symptom levels tend to be high in the first weeks after the assault and many survivors need assistance to redevelop psychological stability, and/or have a need for supportive contact. Such sessions need to be offered as a separate aspect of service as even if counsellors were available on short notice to pick up new clients, it could be inappropriate and unethical whilst containing the crisis to open up the narrative of the abuse to get sufficient information to begin a claim for ACC cover.
In all this, you’re dealing with so many people, yet they expect you to be able to – like the police expect you to be able to ring up and make phone calls.
You’re not in a position to make phone calls, you’re not in a position to speak to all these different people, you’re at your lowest point, and your most vulnerable… you don’t want to be the one to chase people, you need it all there for you… I think the problem is, although it’s available, they don’t realise how easy it needs to be… not ’cause people aren’t determined to get support, but because everything’s hard work, when something like that ’s happened… I needed them to ring me. I can’t emphasise enough that you’re not in a position to do things for yourself. You can’t go and find the help you need, you can’t. (St Mary’s service user, Interview 11, Undetected Offender, p. 54).
6. Follow-up service
- Co-ordinated follow-up including telephone, e-mail, text or face to face communications and liaison with other support agencies
Depending on client need, arrangements with clients and course of case, this service might operate for anything from 1 month to multiple years.
For many survivors, sexual abuse or assault continues to impact their lives for some time. There is a personal journey of adapting to the fact that this has happened and what it means for you, and we live in a world in which portrayals of people being sexually objectified are everywhere, and sexual violence is most often encountered as prime time TV entertainment. Some survivors need on-going professional assistance, while for others they need someone they can talk about it to as appropriate social support is often not forthcoming from friends and family as people don’t want to talk about it or don’t know what to say.
US - Rape has a high impact. Research invariably shows that rape has high psychological consequences in the first few weeks and months with up to 95% of survivors meeting criteria for PTSD. Further, while many survivors do improve significantly by three to four months after the event, many do not. Significant proportions of survivors continue to report anxiety and depression many years after the rape. E.g. Rothbaum, Foa, Riggs, Murdock & Walsh (1992).
Bryant (2003). We don’t yet fully understand predictors of PTSD e.g. one review suggests that of those who meet criteria for ASD, approximately ¾ go on to PTSD. However, also approximately half of people who develop PTSD did not experience ASD in the initial month, and 5% experience delayed onset (more than 6 months after the event).
UK – Lovett, Regan & Kelly (2004) – While in this sector there has often been debate about whether services should call survivors, or wait for survivors to call them to be less intrusive and more client-centred, in this study 78% of survivor/respondents supported the idea of proactive follow-up, though with a range of opinion on optimum timeframe for first contact – within a few days 37%, after a week 33% and after a couple of weeks 30%.
Pro-active follow-up also had an impact on withdrawal, with 30% of those contacted only once withdrawing, reducing to 20% of those contacted 2-10 times.
This role is to work alongside the survivor to provide support through and information about police, prosecution, courts, and corrections re progress of case and to communicate this to the survivor regularly and appropriately. In addition, to arrange other services the client might need (e.g. court preparation) and appropriate return of property held as evidence.
Many survivors want information about what is happening in legal processes so that they know whether they are physically safe or not, when they are going to need to think about the assault again, and in general to maintain some sense of control.
UK – Lovett, Regan & Kelly (2004) – When there was not a “case tracker” 64% of respondents thought that they had not been well informed about the case. Of those who had a “case tracker” service, 75% praised the accurate information that they had been given and almost all respondents were satisfied with the service.
In the end I initiated it and said, “you’ve got to send us more letters, tell us what the hell is going on”, because there were times when they’d say, “look, the trial’s here”, but then you didn’t hear and then you’re waiting to go to trial and then someone phones and says, “oh no, it’s not happening for another six months”. You’re going in like a roller coaster here, there was no communication to say, “no, it’s not actually going to be happening”. That was really hard, I actually suffered every time that happened.
Emotionally you do, trying to prepare yourself for it. I said, “I know this is only another job to you.” For some of them it wasn’t, they were really involved, but I said, “I’m thinking about this every day. You’ve got three that you’re thinking about. Every single day”....They probably felt that they were doing enough, but when you live with something day by day, it’s not enough.
You need to know this guy is going to be put away or whatever you’re feeling, and he’s not going to be out there. Just those little silly things: are you making sure he can’t get out? He can’t get bail, can he? Because you don’t know...It would have been nice if there was someone to answer those questions and not feel silly about it.
Helen (Jordan, 2008 pp. 67-68)
8. Court Services
- Court preparation
- Advocacy and liaison through court processes when possible and appropriate
- Court support – trial, verdict, sentencing, restorative justice referral, parole applications, release
- Emotional Harm and Victim Impact Reports
The nature of the adversarial system can be very hard on the survivor (and her family/supporters) – she (or he) is a witness only so has no legal representation in this process other than what the Prosecutor can provide alongside their duties for the State; her credibility is questioned; she (or he) sees the offender, and must tolerate him seeing her (or him); and she (or he) has to tell intimate details of her (or his) experience and feeling to a public room where not everyone is even sympathetic. It is described by some survivors as the hardest thing they have ever had to do. Further, court processes are offender focussed, and police and prosecution have clear roles to perform regardless of how empathic they are towards the survivor.
Because re-traumatisation as a result of a Court process is so common, it is essential that survivors are offered the option of an independent support worker to assist them through these processes, both during the trial and in the preceding weeks to become familiar with what will be required of them and the environment in which it will occur, to assist with ensuring that appropriate court applications are made and to develop strategies for managing the emotions associated with this often difficult process.
It is important that the person providing support in court is someone who is able to “focus on what the victim/survivor needs rather than venting their own emotions” (Jordan, 2008, p.90), as can be the case when a family member or friend is the designated support person. It is hard to see people we love go through these experiences and be maligned. While family and friends can still attend and be supportive, the survivor is allowed to keep just one person with her (or him) through all processes.
Because all of a sudden I saw myself as being tied up, naked, gagged and being left on the bed by this man, and that was why court was so traumatic, because all of a sudden you saw what had really happened. That this person got off on seeing you, that was and that was really horrible, that was really damaging to see that perspective.
Gabriel (Jordan, 2008, p. 124).
Note : Independent Sexual Violence Advocates
Over recent years, it has been recommended and proposed that New Zealand adopt the UK model of having Independent Sexual Violence Advocates who advise survivors on legal options and procedures, and are the communication bridge for the survivor with police and prosecutors. They perform parts of the call-out roles, case tracker roles, court support roles and Specialist Victim Advisor(MOJ) roles. We support the clear addition of the communication and legal information functions to the roles of sexual assault support services, but note that this configuration is often reported without the emotional and psychological support currently provided by specialist crisis support workers in New Zealand. We understand this as crucial to the reduction of post-traumatic mental injury, and note that Rape Crisis groups in the UK include emotional support in their definitions of the role. In terms of whether all of these functions are best performed in one Role or multiple roles, we suggest that this is best decided at a local level depending on need and resources – the functions might all be able to be covered in one role in areas of low demand but in larger areas might be split to accommodate high demand and to promote specialization.
The role was recommended by McDonald and Tinsley (2011) following their research into current practice in New Zealand, and the ways that the criminal justice system works for survivors of sexual violence in various parts of Europe. They recommend that the role also encompasses the current role of Specialist Court Advisors. An evaluation of the role published in 2009 found the service provided to be of great value to survivors. McDonald and Tinsley note that this value was also seen by The Government Response to the Stern Review - “ ISVAs are so crucial to the way that ‘the State fulfils its obligations to victims of violence [that] funding should be available in all areas where the demand makes a post viable”.
9. Information bank
- Knowledge of great app and internet resources such as Living Well – Supporting Men, and www.dearem.nz
- Specialist libraries – books, DVDs, tapes.
- Web information – regularly updated.
- For survivors and their support networks
- Sexual violence remains relatively “secret” in our society so resources are not easily available through usual means such as the local library or DVD store.
- Many survivors are not able to “take in” much information if they are significantly impacted by the assault. Giving pamphlets means that they are able to access the information when they are ready.
- Much misinformation exists in our communities which can harm survivors. Giving accurate information to friends and family can offset this.
Bryant (2003). In terms of understanding the pathways of the development of PTSD: “It is apparent that the appraisals of the symptom, rather than the symptom itself, may be critical in determining the influence it will have on subsequent adaptation” (p 793). Information about common responses to sexual violence can give context for people making these symptom appraisals.
10. Resource bank – acute practical need
- Clothing Transport.
- Safety – alternative accommodation, respite care, alert systems, changing locks.
- Clothing is often necessary when it has been destroyed in the assault, is triggering to the assault, or is taken as evidence.
- Transport can become an issue for survivors who develop high levels of anxiety – some feel that they can no longer travel on public transport and others can no longer drive in situations they find stressful.
- Emergency housing is needed in many instances of sexual assault, because the victims are not safe to return home, or because they do not wish to return to the place where the assault occurred. For some “homeless” people, a previous sense of safety which meant they felt safe enough to live this way can be undermined by the sexual assault.
- Feeling safe is an important step in recovering from the anxiety often caused by sexual assault. Many survivors can’t get this staying alone, or without adding extra fortifications to their homes.
- When an assault has taken place in a home or a car, to return to that place with detritus from the assault and the police investigation still visible can be further retraumatising. Funding for services to contract cleaners would assist with returning home and to functioning in life.
- Money can be important following assault – a person may not be able to work, may need to replace broken clothes or other items, need to catch taxis instead of buses, need a holiday or to treat themselves well, and may need to reduce other stressors to be able to cope with the impact of the assault.
UK – Lovett, Regan, & Kelly (2004) – in the acute aftermath of a sexual assault, many survivors needed assistance with practical matters.
11. Social work support
e.g. assistance with Work and Income and accommodation, as well as consultations and liaisons re child safety, and crisis support work.
Whether due to the impacts of repeat victimisation, or other factors, services see many survivors who are not well resourced in the world, whether that be financially, socially or other. Sexual violence can also cause massive disruption to individuals and to family functioning. The safety of adults and the safety of children are often issues to be attended to.
12. The above to be integrated with recovery and support services including:
- Support groups
- Services for those supporting survivors – family and friends.
Service integration enables both acute and longer term needs of survivors to be met by a provider with whom they can develop a trusting relationship. This maximises survivor access over time to services which are designed with their needs in mind.
USA - Wasco (2004) – took pre-counselling and post-counselling measures: a post-traumatic stress index PSI and a scale called Counselling Outcome Index (COI) containing items relating to support, trust of self, attribution of blame for the assault, capacity to talk about thoughts and feelings about the assault. This scale was developed collaboratively between the researchers and service providers. Results showed significant differences on all items following counselling. Half of respondents had ten or more sessions.
Prevention and education services
The prevalence and negative impacts of sexual violence are such that if it was an infectious disease, it would be called a pandemic and massive efforts would be in place to prevent it. The fact that it is a social ill rather than a medical ill should not matter in terms of the energy and resources our communities devote to ending it. Funding is required to provide prevention and education initiatives in a population approach, but also for small local programmes responding to local need and opportunity.
Advocacy – to end sexual violence, to improve conditions for survivors
We must end sexual violence. As with prevention, specialist services are those in our communities who are aware of the real face of this violence. To be true to every survivor we support, we must advocate to improve the systems that they deal with, resources available to them, their access to real justice and to stop sexual violence.
13. Other services as locally determined
Services work to serve survivors within their local communities as fully as possible. This might mean that they offer a wider array of services than those usually considered associated with sexual violence so that survivors in their area can get that service. Conversely, resources available in a particular community might provide the opportunity for development of innovative services for survivors.