Kristen Muché California State University, Long Beach School Of Social Work May 2013

1. SANCTUARY:A Content Analysis of Literatureon Trauma-informed Psychiatric Inpatient Treatment for Female Survivors of Rape and Sexual Assault Under Involuntary Hold Kristen Muché California State University, Long Beach School Of Social Work May 2013

2. Introduction Problem: • Majority of inpatients in acute psychiatric settings have histories of trauma, especially sexual violence • Often times, the external coping mechanisms for these individuals appear in the form of self-injurious behaviors, which are then responded to by professionals with the mindset of impending suicide • Lack of education and training regarding the connections between sexual assault and coping mechanisms continues to be reflected in the modern interventions utilized within psychiatric settings, as systems stemming from the medical model versus an empowerment model are still in place • For this reason, a paradigm shift is warranted, so as to reduce the risk of re-traumatization for rape and sexual assault survivors under involuntary hold, within these institutions Purpose: • To gain a better understanding of the issues faced by involuntarily held female survivors of rape and sexual assault within acute inpatient psychiatric settings and explore what existing inpatient trauma-informed training was in place Question: • How have acute inpatient psychiatric units demonstrated trauma-informed practices in their treatment of Danger to Self (DTS), or suicidal, female patients who are also rape and sexual assault survivors?

3. Social Work Relevance • Quality of Life • The extent to which the culture of rape and sexual assault among survivors, as presented in the reviewed literature, was explored, and recommendations for new areas of research were made, so that quality of life can be increased • Sensitivity Training • The ultimate goal of this study was for all acute inpatient psychiatric facilities to adopt trauma-informed training requirements within their departments, so that the rate of re-victimization among rape and sexual assault survivors will decrease

4. Cross-Cultural Relevance • Viewing mental health facilities and hospitals as microcosms • Rape and sexual assault survivors represent every race and ethnicity across the board (Rozée, 1993; Holmes, 2002) • Culture shock of psychiatric wards (Rozée, 1993; Holmes, 2002) • Part of the desired experience, in trauma-informed care, is for survivors’ cultural, religious, racial, ethnic, gender, and sexual orientation identifications to be inquired after and carefully considered, especially in understanding their own perspectives, or interpretations, of what has happened to them (Underwood et al., 2007; Holzman, 1994). • Studies from multiple countries were utilized for the purpose of assessing similarities and differences among trauma-informed care and its impact on rape and sexual assault survivors, in addition to evaluating attitudes and understanding regarding involuntary hold, restraint use, seclusion, and significant clinical variables among this population

5. Methods • Research Design: • Systematic review of literature based on a content analysis method • Study Selection and Sampling: • Analyzed 30 empirical studies, published between 2009 and 2012, that reported findings on the independent areas of the following: • Female rape and sexual assault survivors; acute inpatient psychiatric environments wherein involuntary hold, restraint use, and seclusion were practiced; and trauma-informed services • Data Collection Method: • Multiple research databases, including EBSCO Host and PsycINFO; professional journals of social work, psychology, mental and psychiatric health care, and related disciplines • Data Analysis: • Content was analyzed based upon the most common influencing factors. In analyzing the findings of these empirically based studies, the researcher identified three significant findings, two recommendations for future research, and two limitations within each study, chosen on the basis of relevance to this study

6. Results • Majority of acute inpatient psychiatric units consist of individuals with mood, anxiety, and substance-related disorders • Majority of individuals with mood, anxiety, and substance-related disorders are rape and/or sexual assault survivors • Majority of acute psychiatric inpatients are rape and/or sexual assault survivors • Parallel with self-injurious/parasuicide behaviors (e.g. cutting or self-mutilation without the intent to kill), as self-blame and isolation were often paired with post-rape or sexual assault incidences, leaving survivors in a state of hopelessness and dead ends, in terms of emotionally supportive resources • Need for trauma-informed care, education, and implementation among staff is dire, as the coercive measures in place appear to produce extremely negative effects on rape and sexual assault survivors, hurting and disabling them rather than caring and empowering them • Lack of awareness to this connection between psychiatric patients and survivors, in that the majority of them are one in the same

7. Results Cont’d. Psychiatric programs with trauma-informed care and training in place significantly increased survivors’ levels of functioning, perceptions of being understood and not judged, and both rate and quality of recovery • Unlike the programs that did not have trauma-informed care in place, which, as a result, had catastrophic effects on survivors, including, but not limited to, re-traumatization and re-victimization, stereotyping, ignorant and objectifying interventions, and victim-blaming tactics Need for partnerships between community sexual assault centers and psychiatric inpatient hospitals and units Areas of suicidality, sexual assault, and involuntary commitment shared common concerns and risk factors, whereas the studies on trauma-informed care not only presented findings complementary to these concerns and risk factors, but also confirmed the response to the recommendations and future research statements made by these study areas • Studies on trauma-informed care responded to this by providing multiple frameworks for these interactions to take place, in newly devised policies and training systems that identified precious knowledge and empathy as the basis for this paradigm shift to begin

8. Implications for Social Work • Self-injurious behaviors are misunderstood and should be re-evaluated as maladaptive coping mechanisms, rather than exclusively as suicide attempts • A step between being identified as a threat to one’s self or others and involuntarily held should be taken, encouraging dialogue in both an emotionally and physically safe space • Partnerships with sexual assault agencies should be established, so that PET members would, first, be trained in identifying symptoms specific to sexual trauma and, second, assess whether or not the identified person would be more appropriate (i.e. receive better customized treatment) for a sexual assault crisis facility or a locked down acute psychiatric inpatient facility • Reporting parties should be trained in trauma-informed care, so that once an external symptom of trauma or self-injurious behaviors manifest in a client, these parties can engage in dialogue and trauma assessment, so that the decision to involuntarily hold a client is not prematurely made

9. Implications for Social Work Cont’d. • Dissociative and rage-like features were also attributed to the high volume of rape and sexual assault survivors within acute inpatient psychiatric facilities (Klanecky et al., 2008; Painter & Howell, 1999) • These characteristics keep with the intensely elevated and unstably impulsive features experienced in individuals with Bipolar I Disorder: Manic Episode, dissociative disorders, and Borderline Personality Disorder, which are largely prevalent among survivors of rape and sexual assault, primarily those with histories of childhood sexual abuse (Gallop et al., 1999; Sansone et al., 2011) • Further research for how these features could be misinterpreted as exclusively psychotic or attributed to Schizophrenia, possibly leading to survivors internalizing the notion that they are “going crazy”, and not a history of rape and/or sexual assault, could provide a deeper insight into an area that seems to be quite relevant to this study’s findings, as well as provide even more incentive for mandatory trauma-informed care training

10. References Gallope, R., McCay, E., Guha, M. & Khan, P. (1999). The experience of hospitalization and restraint of women who have a history of childhood sexual abuse. Health Care forWomen International, 20, pp. 401-416.   Holmes, J. (2002). Acute wards: Problems and solutions: Creating a psychotherapeutic culture in acute psychiatric wards. Psychiatric Bulletin, 26(10), 383-385. Holzman, C. G. (1994). Multicultural perspectives on counseling survivors of rape. Journal ofSocial Distress & the Homeless, 3(1), 81-97. Klanecky, A. K., Harrington, J. & McChargue, D. E. (2008). Child sexual abuse, dissociation, and alcohol: Implications of chemical dissociation via blackouts among college women. The American Journal of Drug and Alcohol Abuse, 34, pp. 277-284. Painter, S. G. & Howell, C. C. (1999). Rage and women’s sexuality after childhood sexual abuse: A phenomenological study. Perspectives in Psychiatric Care, 35(1), pp. 5-17. Underwood, L., Stewart, S. E. & Castellanos, A. M. (2007). Effective practices for sexually traumatized girls: Implications for counseling and education. International Journal ofBehavioral Consultation and Therapy, 3(3), 403-419. Rozée, P. D. (1993). Forbidden or forgiven? Rape in cross-cultural perspective. Psychology ofWomen Quarterly, 17, 499-514. Sansone, R. A., Chu, J. W. & Wiederman, M. W. (2011). Sexual behaviour and borderline personality disorder among female psychiatric patients. International Journal ofPsychiatry in Clinical Practice, 15, 69-73.