Making Connections between Addictions, Mental Health and Woman Abuse/Sexual Violence/Trauma

1. Ontario Woman Abuse Screening Project May 2010 Making Connections between Addictions, Mental Health and Woman Abuse/Sexual Violence/Trauma Linda Murray, RN, BScN Sexual Assault Nurse Examiner Abused Women’s Service, Sexual Assault/Domestic Violence Treatment Centre, Chatham-Kent Health Alliance Tonya Verburg Residential Manager Chatham Kent Women’s Centre

2. Woman Abuse

3. Woman abuse is any threat, act or physical force that is used to create fear, control or intimidate you.

4. Woman Abuse: Incidence and Prevalence • 25% of all women have experienced physical or sexual violence at the hands of a marital or a common law partner • 45% of incidents resulted in injury • In 85% of family violence cases reported to police, the victims were female • Women are 7 times more likely to be killed or hurt in their homes by someone known to them than by a stranger • 60 % of women do not report abuse to police DATA: Justice Statistics, Statistics Canada, 2006

5. Violence against women is not about losing control. It is the intentional control of another person. The abuser is purposefully using verbal, non verbal or physical means to gain control over the other person. In most cases the abuser is not abusive or violent to others outside the family or home.

6. Power and Control • With all abuse, the abuser uses power over those they are abusing. Abusers often use alcohol or drugs as an excuse. But the abuser is responsible for his or her behaviour Data: Spousal Abuse Fact Sheet, Family Violence, Department of Justice

7. Abusers are able to control their behavior—they do it all the time. Abusers pick and choose whom to abuse. They don’t insult, threaten, or assault everyone in their life who gives them grief. Usually, they save their abuse for the people closest to them, the ones they claim to love. Abusers carefully choose when and where to abuse. They control themselves until no one else is around to see their abusive behavior. They may act like everything is fine in public, but lash out instantly as soon as you’re alone. Abusers are able to stop their abusive behavior when it benefits them. Most abusers are not out of control. In fact, they’re able to immediately stop their abusive behavior when it’s to their advantage to do so (for example, when the police show up or their boss calls). Violent abusers usually direct their blows where they won’t show. Rather than acting out in a mindless rage, many physically violent abusers carefully aim their kicks and punches where the bruises and marks won’t show.

8. Originally developed byThe Domestic Abuse Intervention Project, Duluth, USAFurther adapted byLondon Abused Women’s Centre

9. Power and Control Exercise • Create a power and control wheel for women you work with, either with Mental Health Issues or Substance Abuse Issues • How are the tactics of abuse related to women’s use of drugs or their mental health

10. Using Intimidation, Threats and Coercion Using Emotional Abuse Putting her down, making her feel bad about self, feel guilty about past or present drug use, or MH condition Threatening to hurt her if uses/does not use, hurt if goes to doctor, etc Using Economic Abuse Physical Abuse Forcing into prostitution, forcing to sell drugs, prescribed or illegal, calling boss with concerns of MH, Physically abusing her for her condition, for getting high, for not getting high POWERAND CONTROL Using Isolation Encouraging Dependence Keeping her away from supportive people, preventing her from attending treatment Introduce to drugs, buying drugs for her, make her think she needs meds for MH, post partum etc. Making light of condition, saying she caused abuse by drug use or Mental illness Treat her like a sex object, withhold sex or force even if traumatic, forcing into prostitution Minimizing, Denying, Blaming Sexual Abuse

11. Video It’s not like I hit her

12. Cycle of Violence NOTE: Cycle of Violence is not the reality for all women

13. Women Who Face Additional Challenges • Rural Women • Geographic location • Isolation • Lack of transportation and other services • First Nations Women • High incidence &normalization of violence in First Nations community • absence of public education about women’s legal rights • often a First Nations woman has to leave her community to be free of the abuse

14. Immigrant Women • fear of jeopardizing their immigration status, • often economically dependent and financially insecure • language barrier • fear deportation and losing children • Women with Disabilities: • difficult to leave if abuser is caregiver, • barriers to access services, neglect is very prevalent in abusive relationship • viewed and treated as children, • considered to be non sexual • caregivers often seen as good people for taking on such a challenge

15. The Number One Question • Why Does She Stay? More appropriate questions would be… • Why Does He Abuse Her or • What Prevents Her From Leaving

16. She believes he will change • Fear • Economic Reasons to Stay/Return • Pressure from Community or Faith or Family • Guilt or Self Doubt • Concern for Children • Lack of Community Support • Demands of Family Court Process • Stockholm Syndrome • Abused women leave an average of 8 times before leaving for good

17. Common Effects of Abuse-Related Trauma: • Fearing people and relationships • Substance misuse and abuse (includes self medicating) • Difficulty sleeping or over sleeping • Flashbacks of the abuse • Dissociation • Having panic attacks or uncomfortable amounts of anxiety • Low self-esteem and self-loathing • Depression • Repeated experiences of being revictimized (continued abusive relationships) • Suicidal ideation or suicide attempts • Nightmares • Memory Gaps (especially from childhood) • Self-harm • Eating Disorders (Adapted from: What do these signs have in common? Recognizing the effects of abuse-related trauma - CAMH, 2004)

18. Sexual Abuse

19. Adult Sexual Assault Sexual assault is a crime of power, control and anger. It is one person’s attempt to hurt or humiliate another through sex and/or violence

20. What is Sexual Violence It is any form of unwanted sexual activity that is forced upon a person without that person’s consent. Sexual Assault can range from unwanted sexual touching to forced intercourse. While most sexual assault are perpetrated against women, both women and men are sexually assaulted

21. Sexual Assault of Women • Is far more prevalent than sexual assault of men • Almost 40% women have reported at least one assault from age 16 Statistical Trends 2006 Ottawa: Statistics Canada, 2006

22. Sexual Assault of Women • Women make up more than three quarters of all reported sexual assaults • Young women ages 15-25 making up more than half • Majority of all reported sexual assaults on women are perpetrated by men they are acquainted with Sexual Offences in Canada, Ottawa: Statistics Canada,2003

23. Statistics • 25% of women experience unwanted sexual touching • Another 24% experience violent SA • 38% SA by husband, partner, boyfriend • 54% of girls under 16yrs experience unwanted sexual attention • 24% experience rape/coercive sex • 17% experience incest • Only 6% SA reported to police – of these, 63% are girls under 18 yrs • Only 1% date rapes are reported • 80% of aboriginal women have been sexually assaulted • 83% of developmentally challenged women have been sexually assaulted • 1 in 7 males SA Statistical Trends 2003, Sexual Offences in Canada 2003, Canadian Crime Statistics 2003

24. Vulnerable to Violence • Girls and young women • Women living with disabilities • First Nation women • Women of color • Women living in poverty • Women at war

25. Physical Health Effects • Irritable bowel syndrome • Chronic pelvic pain • Vaginal bleeding • STI’s including HIV infection • Urinary Track Infections • Undetected cervical disease

26. Possible Impact of Sexual Violence Trauma has an impact on the entire person. The possible consequences to sexual violence are exhibited as symptoms within the context of individual experiences. Symptoms are guideposts for intervention to reduce human suffering and to restore well-being for the individual.

27. Impact of Sexual Violence • Rape Trauma Syndrome (RTS) • Post Traumatic Stress (PTS) • Psychological Manifestations • Relationship Manifestations • Alcohol and Drug Use

28. Rape Trauma Syndrome RTS is expressed in a complex, entangled lifestyle when an individual lacks adequate coping skills or social or medical support, or is subject to ongoing trauma in his or her environment. As time goes on the physical, emotional, social and sexual categories impacted by the sexual assault become less segregated and more intertwined, making the exact nature of a particular problem less obvious.

29. Rape Trauma Syndrome RTS is associated with risk-taking behavior, increased substance abuse, lowered self-esteem, depression and anxiety and a wide range of physical and sexual dysfunction.

30. Substance Abuse Studies • 30.7% of women in a methadone maintenance treatment program had been sexually abused by a partner in the past 6 months and cocaine use increased this violence (EL-Bassel, 2004) • 59% of substance abusers had symptoms consistent with PTSD, yet were undiagnosed at the time they were admitted for detoxification and had not received any treatment (Fullivore et al.,1993) • 97% of women with PTSD reported one or more violent traumas compared to 73% women without PTSD (Fullivore., 1993)

31. Post Traumatic Stress • Persistent frightening thoughts and memories of their ordeal • Recurring distressing dreams of the event • Feeling emotionally numb • Avoidance of stimuli associated with the event • May not show up until years after the event

32. Psychological Manifestations • Difficulty concentrating, hopelessness, anger, depression, eating problems, decreased self-esteem • Denial • 1/3 of rape victims will contemplate suicide • 17% actually attempt suicide • 1/3 of all sexual assault victims will develop PTS sometime during their life

33. Relationship Manifestations • Problems in relationships – family friends, spouses • Shame and guilt – blaming themselves, feeling different from all other human beings • Social problems – difficulty with trust • Sexual problems - avoidance of sexual activity, decreased interest and desire

34. Substance Abuse • Substance abuse, especially with alcohol, cigarettes and cocaine, is common when victims desire to numb or cope with the pain of sexual trauma • In drug treatment programs, 46.4% of patients had a history of sexual assault as adults and 38% in childhood (El-Bassel, Gilbert, & Fry et al., 2004)

35. Trauma and Substance Abuse Data collected from substance abusing women from nine treatment centres across Ontario • 85.7% of 98 women in her sample were victimized • 56.1% adult physical abuse • 56.3% childhood sexual abuse • 56.1% childhood physical abuse • 45.4 adult sexual abuse Cormier, R, A; 2000

36. Child Sexual Abuse

37. Child Sexual Abuse (CSA) Child sexual abuse occurs when a child under the age of 16 is used for sexual purposes by an adult or adolescent. It is emotionally abusive and is a betrayal of trust and an abuse of power over the child. Sexual abuse is often accompanied by other forms of mistreatment.

38. Child Sexual Abuse CSA involves exposing a child to any sexual activity or behavior, whether directly or indirectly. Examples include sexual touching, sexual acts, exhibitionism, pornography and prostitution. The law does not differentiate between the actions performed on a child and those performed by a child.

39. Child Sexual AbuseHistorically • Children are responsible for their own molestation • Mothers are to blame • Child sexual abuse is rare • Sexual abuse does no harm • Children always tell • Children feel negatively about the abuser • All abusers are male • There is little impact for the survivor

40. Who are the Victims • Found in all classes and ethno-cultural communities • Children who have physical or mental disabilities are especially vulnerable to sexual abuse • Children who are isolated – little contact with friends, siblings or adults whom they can trust • Some abusers manage to isolate the child by manipulating people or situations

41. Child Sexual Abuse • CSA is largely a hidden crime • Children often afraid to report • Often fear consequences of disclosing information • Often convinced no one will believe them • Very young children are unable to articulate or understand their experiences

42. Statistics • Children and youth account for 61% of reported sexual assaults • 50% of sexual assaults on children under the age of 6 are perpetrated by a family member • 86% of all reported child sexual assaults are perpetrated by an individual known to the child • Strangers are implicated in only 5% of reported child sexual assaults, and the majority of these are against older teens • 67% of reported CSAs take place in a private dwelling Children and Youth as Victims of Violent Crime, Ottawa, Statistics Canada, 2005

43. Internet Child Exploitation These are relationships initiated online that result in a child or adolescent being lured or misled into a situation that results in attempted or completed sexual abuse or assault or “compliant” sexual activity (“cyber-enticement”)

44. Internet Child Exploitation • Child/adolescent who was sexually abused and photos taken for distribution over the internet • Using online porn images to seduce, groom or desensitize a child/adolescent for the purpose of engaging in sexually abusive behavior with the child/adolescent • Child/adolescent who experiences unwanted online sexual activity • Peer victimization (images shared between peers) • Sexual activity transmitted over the internet via webcam

45. Child Sexual Abuse • Decreased self-esteem • Depression • Increased risk taking behavior • Dissociation • Poor boundary setting • Substance abuse, including alcohol and prescription drugs • Self-harming behaviors • Suicide

46. Lifestyle of Victims of CSA • Unemployment • Homelessness • Increased risk taking • Incarceration, 55% -73% • Abusive relationships

47. Consent • May 1st, 2008 –changes to Age of Consent • Criminal Code was amended • Consent increased from 14 to 16yrs • Close in age exceptions • 12-13yrs - no more than 2 yrs older • 14-15yrs - someone less than 5 yrs older

48. VICARIOUS TRAUMA

49. Vicarious Trauma (VT) VT is described as the cumulative transformative effect of the helper working with survivors of traumatic life events

50. Vicarious Trauma • It affects many aspects of the helpers life not just within the professional setting • Includes typical symptoms of PTS • Also encompasses symptoms of disruptive frame of reference, including disruption in identity, worldview, and spirituality