Assessment Strategies for the Treatment of Trauma - Medicine Essay Example
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As a society, we have awakened to the realism that childhood sexual abuse is a main social problem, and that policies must be established to promise protection of our children. Growing public awareness has resulted in an astonishing boost in reported cases of sexual abuse. Regrettably, as mental health professionals are eagerly aware, we are deeply underequipped to cope with the demands for services brought onward by these disclosures. Not merely are agencies shorthanded for managing sexual abuse cases, the technology for assessment as well as intervention is grossly underdeveloped. A pivotal cornerstone to the development of sufficient social and therapeutic interventions is a development of sufficient assessment technology (Lanyado, 1997).
The profound impact of sexual assault is best understood when it is seen as a violent crime against a person and not as a specifically sexual encounter. Sexual assault is a personal violation accompanied by a loss of autonomy and control. The experience of assault can be viewed as a crisis situation in which a traumatic external event breaks the balance between the individual’s adaptive capacity and the environment. As such it is similar to other traumatic situations described in the literature on stress, including community disasters, war, and surgical procedures. Its unexpected nature and the variability of the victim’s coping resources are critical factors in how the victim responds to this life threatening catastrophe.
Initial reactions to sexual assault range from calm to confusion, anxiety, and extreme emotion. Victims may also demonstrate restricted attention span and automatic or stereotyped behavior. Symonds emphasizes the disordered perception, thinking, and judgment that may occur, and the helplessness and regression, which he terms “frozen fright.”
One type of acute reaction is illustrated by shock, disbelief, emotional disorganization, in addition to disruption of normal prototypes of behavior and function. A posttraumatic stress disorder syndrome has been examined in rape victims. This unexpected, sudden, and serious experience leaves the victim unable to build up adequate defenses. It involves intentional unkindness or inhumanity, makes the victim feel trapped as well as unable to fight back, and frequently involves physical injury. The victim may be powerless to talk regarding what has happened and may have difficulty telling family or friends or accounting to the hospital or police. Guilt may be high, with fears that poor decision may have precipitated the assault.
The impact of sexual assault brings about all levels of a child’s sentiments. Confusion is often the early reaction of the child. Once the abuse starts the victim undergoes an unbelievable divergence with their emotions. They feel pleasing due to the attentiveness they are getting from the parent, as well as the bodily satisfaction. On the other hand they experience pain, guiltiness, as well as annoyance for what is being done.
Child victims of sexual abuse undergo far worse trauma if they think images of their suffering are circulated on the internet, a Welsh conference will hear today. The disgrace of being seen in pictures of exploitation passed among paedophiles leaves children with a heavier psychological trouble (Internet Images Make Child Abuse Trauma Burden Worse, 2004).
The abused will feel significant guilt for a variety of reasons. They think they did nothing to avoid the abuse as a result they are answerable and it should carry on. They felt painful but the abuse was sometimes pleasant. They one way or another earned or caused the abuse. A victim will usually feel this manner when their confidence has decreased and they have no more reactions for what is happening.
Another most significant foundation of guiltiness comes from the mother. Often when the mother is told concerning the abuse she will not want to think the charges and will hold accountable the child.
Other drive for why the mother may pass guilt. She may feel unfitted to tackle the husbands control in any area of life as a result she passes the husbands accountabilities and looks at the child. The mother would not like to lose her husband. She does not want to give up the safety offered by her husband and will disagree with the abuse.
During the abuse period and before disclosure, the character of the abuse, child and family circumstances, and community attitudes and resources interact to decide whether and when a child accounts the abuse and how the child will be affected psychologically as well as emotionally. At the time of revelation, stress and support factors comprise the circumstances leading to the disclosure, household reactions to the confession (e.g., belief vs. disbelief), community stress (e.g., multiple interviews, courtroom testimony), and community possessions (e.g., trained investigators, stress management programs, group therapy). Long-term adjustment may speak about to the child’s ability to conquer associated posttraumatic stress symptoms through a helpful family environment, appropriate treatment regimens, and the achievement of a stable, less demanding life-style. Resolution of abuse-related indications may be caught up by long, protracted courtrelated routines, family upheaval, as well as continued contact with a perpetrator who has not recognized the abuse or its consequences (Lanyado,1996).
Assessing sexually abused children can be conceptualized as a three part, building block procedure. The first task is to describe the background for the assessment. The second is assessing the child’s present psychological adjustment. The third task is assessing those factors that may arbitrate the impact of sexual abuse for a particular person.
What are the objectives for assessment and who will use the results and for what reason? At what point in time is a child being assessed, as associated to the abuse, discovery, court, and treatment? What were the situation surrounding the sexual abuse, in addition to what happened sexually? What other stressors are happening that might affect psychological adjustment? What other types of mistreatment or trauma have affected the child? Intrinsic in conducting an assessment of related variables is obtaining precise historical information from knowledgeable informants, interviewing the child regarding the details of the abuse, assessing the reality of the child’s allegations, and determining the demands that will be placed upon the child from the society, counting courtroom testimony (Edwards, Maltby, 1998).
History of Victimization Form
In lieu of interviewing the child directly regarding the particulars of the abuse, the examiner may demand such information from other professionals concerned with the child (e.g., police, social workers). The History of Victimization Form was built up to get hold of detailed information from social workers concerning the child’s mistreatment, and allow for objective assessment of the harshness of a variety of forms of child maltreatment. The form has five scales: sexual abuse, physical abuse, ignorance, experience to family violence, and psychological abuse. In addition to offering object data regarding the events linked with each form of maltreatment, the social workers are also inquired to rate the harshness of the abuse from 1 to 5, using their own experiences with similar cases as the standard of contrast (Horne, 2001).
Each scale contains a Gutman-like checklist of quite a few abusive behaviors, listed in a rising order of severity. Together with each checklist are quite a few questions designed to valve factors linked to the severity of mistreatment: physical sequelae to the abuse, the relationship of the child to the doer, the emotional “closeness” of the doer to the child, and the time frame, duration, and incidence of the abuse. For the Sexual Abuse scale, the type and extent of force or coercion used to gain fulfillment is also assessed. Also, the informant is asked whether he or she believes the sexual involvement finally elicited the child’s sexual response ensuing in eroticism.
A factor analysis of the History of Victimization Form Sexual Abuse scale, based upon 48 subjects, exposed two orthogonal factors. The first labeled “route of abuse” included duration, incidence, and relationship between child and perpetrator. The duration as well as frequency variables emerge to relate to the relationship to perpetrator variable for the reason that those perpetrators who were closer to the child tended to exist within the same home as the child and consequently had more unsupervised access to the child. The second factor, “seriousness of abuse,” incorporated type of sexual acts, force or coercion, and number of perpetrators. The track of abuse factor accounted for 31% of the total variance, and the gravity of abuse factor accounted for 34% of the discrepancy, altogether accounting for 65% of the total variance (Hopkins, 2000).
Parent Impact Questionnaire: This form was designed to offer an objective format for gathering background information from mothers during the assessment of their child’s sexual abuse sequelae. Maternal reactions to the abuse revelation may relate strongly to the child’s aptitude to get well from the sexual abuse. consequently, it is significant to assess the mother’s reply to the trauma, her belief of the child’s story, in addition to her experiences since the time of disclosure (Dockar-Drysdale, 1990).
The Parent Impact Questionnaire has four sections: a brief explanation of the family-related problems that the mother experienced during childhood and as an adult, the mother’s history of sexual abuse as a child, the impact of the revelation for the mother and the family, and the mother’s insight of events regarding the sexual abuse. For the first section, two sets of questions are asked: “As a child, did you experience any of the subsequent family-related problems?” Response options comprise parental separations or divorce, extreme parental arguing, physical fighting between parents, insufficient housing, parental alcohol or drug abuse, parental mental health problems, inadequate notice to physical needs (e.g., poor nutrition), and extreme physical punishment. If the parent responds positively to any items, further questioning can be pursued, including information about what happened and when, their age at the time of the abuse, and how the experience affected them. The next question is “As an adult, have you experienced any of the following?” Response options comprise: marital separations or divorce, physical violence from your partner or boyfriend, drug or alcohol dependence, in addition to mental health problems or sufficient magnitude to see a mental health professional (Hamilton, 1996).
The second section regards the mother’s history of sexual abuse or assault. Adapted from the interview format built up by Finkelhor and his colleagues (Finkelhor, 1979) for assessing the epidemiology of childhood sexual abuse experiences by interviewing adults, the following questions are asked: “Do you remember any sexual experience or set of experiences that happenned before the age of 16, which you did not say okay to? That is, a sexual experiences which was forced on you, done in opposition to your will, or which you did not want to occur?” If the respondent indicates “yes,” then she is asked “How many sets of experiences?” A follow-up question is asked: “Do you remember any sexual experience or set of experiences before the age of 16 that concerned someone at least 5 years older than you and was/were not forced on you in opposition to your will?” If the mother responds “yes” to either question, the following information is obtained: age of respondent at the time of the abuse, age as well as sex of perpetrator, relationship to the perpetrator, time period over which the abuse occurred, whether the mother disclosed the abuse to anybody or to an official agency, and whether charges were filed and the result of those charges (Alvarez, 2000).
The third section looks upon the impact of the sexual abuse and disclosure on the family and the mother. The first fraction of the section asks “As a result of what happened to your child, how have things changed for your family?” Thirty-one states of affairs are listed, categorized as family constituency, family relationships, and participation with social agencies, legal proceedings, therapeutic interventions, as well as social relations. The second part of this section is the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979). This scale contains 15 items that recount to invasive thoughts and avoidance regarding a traumatic occasion, in this case the child’s sexual abuse, disclosure, and resulting sequelae. Respondents rate the occurrence of symptoms on a 4-point scale from not at all, to hardly sometimes, and often.
The fourth section contains five main questions designed to evaluate the mother’s awareness of events regarding the sexual abuse, personal responsibility and guilt, treatment by investigative as well as legal agencies, and type of interventions the parent would like to see accessible to her child and family. With the exception of the last question, all questions necessitate rated responses, which are provided along an anchored 5-point continuum (Alvarez, 1992).
Frequently, one of the main reasons for the referral is to set up the details of a child’s story about the sexual abuse. This is usually referred to as an investigative interview. Investigative interviews must be conducted with two primary goals in mind. First, a thorough description of the sexual abuse experience should be attained, taking care not to influence the child’s story by differential reactions to a variety of aspects of the story, or by using leading questions unnecessarily. Second, an investigative interview serves as a child’s introduction to the “helping” community and must be conducted in a therapeutic atmosphere that would assist further involvement with helping professionals. Despite the legalistic aspect of the interview, the key to a flourishing interview is to acquire the information in a therapeutic manner (Klein, 2003).
Investigative interviews are frequently conducted by a number of professionals, including police, social workers, as well as psychologists. Investigative interviewing must be considered a specialized skill that is reserved for those specially trained in child sexual abuse, child development, cognitive processes, and therapeutic interviewing of children (Horne, 1999).
Investigative interviews be conducted over a number of sessions, progressing at a rate comfortable to the child. The first meeting should focus on building relationship, general development, and adjustment to school, peers, and family. A broad standard for facilitating rapport is to assess a child as a “whole person” and avoid nuances that the only significant aspect to the child is that he or she was sexually abused.
When interviewing the child about the sexual abuse particulars, significant information includes the name of the perpetrator, the child’s relationship to the perpetrator, duration as well as frequency of the abuse, particulars of the sexual behavior including places as well as circumstances surrounding the abuse, date and time of the last incidence, whether anyone else was involved or observed the abuse, whom did the child tell regarding the abuse, and the sequence of disclosure, who knows about the abuse, methods used to increase the child’s compliance, grounds for disclosure, and the child’s understanding of the current situation and upcoming events.
Considering the investigative interview as the preliminary step in therapy, children can also be asked regarding what they felt before, during, and after the abuse as well as perceptions of their role in the abuse. The child’s understanding of the perpetrator’s deviance, as well as the child’s understanding of human sexual interaction can also be discovered. A child’s right to freewill in the interview be placed at equivalence with the goal to get hold of complete and accurate information. Interviews must not last too long; children be reminded frequently that they can end the interview or change topics whenever they feel uncomfortable. Paradoxically, children were in fact more likely to provide information when she offered many opportunities for them to avoid the topics (Hartnup, 1986).
To make the most of accuracy of the information, the interviewer should take steps to guarantee that he or she does not influence the child’s story. The interviewer should remain comparatively uninformed about the case until after the interview with the child. Videotaping the interview not merely to evade multiple interviews by other professionals, but also to be used as a reliability check when reviewing the interview. Open-ended questions assist avoid foremost the child’s response, and have a tendency to produce the most accurate, even though unfinished, accounts of events. Asking the child to recall the event soon after it occurred can have the benefit of facilitating recall several months later. Nonetheless, even when questioned after a number of months for the first time, children’s remember for important and salient events is usually accurate, even though less complete. As the occurrence of a parent might influence a child’s story, interviews should be conducted devoid of their presence. Once the investigative interview is complete, on the other hand, some professionals propose interviewing the child in the presence of both parents, chiefly when there is a custody as well as access dispute. However, interviewing the child in the presence of the accused perpetrator enlarges the prospective for withdrawal of the story or alteration of the story such that the accused parent is no longer implicated.
Alvarez, A. (1992) Live Company: Psychoanalytic Psychotherapy with Autistic, Borderline, Deprived and Abused Children. London: Tavistock/Routledge.
Alvarez, A. (2000) ‘Moral imperatives with borderline children: the grammar of wishes and the grammar of needs’, in J. Symington (ed.) Imprisoned Pain and its Transformation: A Festschrift for H. Sidney Klein. London: Karnac.
Dockar-Drysdale, B. (1990) The Provision of the Primary Experience: Winnicottian Work with Children and Adolescents. London: Free Association Books.
Edwards, J. and Maltby, J. (1998) ‘Holding the child in mind: work with parents and families in a consultation service’, Journal of Child Psychotherapy, 24(1): 109-33.
Finkelhor, David. 1979. Sexually victimized children. Free Press, New York.
Hamilton, V. (1996) The Analyst’s Pre-Conscious. Hillsdale, NJ: The Analytic Press.
Hartnup, T. (1986) ‘Children and institutions II: the professional and the institution’, Journal of Child Psychotherapy, 12(2):41-54.
Hopkins, J. (2000) ‘Overcoming a child’s resistance to late adoption: how one attachment can facilitate another’, Journal of Child Psychotherapy, 26(3):335-47.
Horne, A. (1999) ‘Normal emotional development’, in M. Lanyado and A. Horne (eds) The Handbook of Child and Adolescent Psychotherapy: Psychoanalytic Approaches. London: Routledge.
Horne, A. (2001) ‘Brief communications from the edge: psychotherapy with challenging adolescents’, Journal of Child Psychotherapy, 27(1):3-18.
Internet Images Make Child Abuse Trauma Burden Worse, 2004. Newspaper article; Western Mail (Cardiff, Wales), May 28.
Klein, J. (2003) Jacob’s Ladder: Essays on Experiences of the Ineffable in the Context of Contemporary Psychotherapy. London: Karnac.
Lanyado, M. (1996) ‘Winnicott’s Children: the holding environment and therapeutic communication in brief and non-intensive work’, Journal of Child Psychotherapy, 22(3):423-43.
Lanyado, M. (1997) ‘Memories in the making: the experience of moving from fostering to adoption for a five year-old-boy’, Journal of the British Association of Psychotherapists, December: 3-18.