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Learning from experience: psychologists' inquiry into child sexual abuse in therapeutic settings

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Abstract

Childhood sexual abuse (CSA) has devastating psychological and emotional consequences for survivors. Many clients who attend therapy have experienced CSA, however spontaneous disclosure of CSA during therapy is rare and psychologists often fail to inquire. This study seeks to explore experiences of inquiry from psychologists with specific knowledge and experience in CSA. Seven psychologists across Australia were interviewed to explore their experiences of inquiry into CSA. De-identified transcripts were analysed using interpretative phenomenological analysis. When and how psychologists inquired varied depending on client factors and therapist factors, with some participants opting for direct inquiry whereas others utilised indirect inquiry. Psychologists were similar in their responses to disclosure of CSA, with all participants advocating for an empathetic response, while managing their own emotions. Participants described learning how to inquire about and respond to CSA from their experience of working with clients, supervision, and further research and training. Practice impact statement Many clients who attend therapy have experienced CSA, however spontaneous disclosure of CSA is rare, and psychologists often fail to inquire. Improving access to information from psychologists experienced in CSA is essential to build confidence and professional competence, particularly for early career psychologists.

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Despite the high prevalence of child abuse amongst users of mental health services and the many long-term sequelae of abuse, it has been demonstrated, in New Zealand and elsewhere, that mental health professionals are frequently unaware of clients' abuse histories. In response an urban District Health Board has introduced policy guidelines that all mental health clients must be asked about sexual abuse and other trauma, and that all mental health staff must receive training designed to improve confidence and competence in relation to inquiring about abuse, and responding to disclosures. This paper summarises the New Zealand and international research that informed the design of the training programme, and presents an evaluation of the first seven administrations of the programme, to 85 mental health staff from a range of professions. The programme was highly valued by participants, was effective in improving confidence, knowledge and some of the relevant beliefs, and improved actual clinical practice for a proportion of the staff.
Article
A hidden rape victim is one who has never reported her experience to a rape crisis center or to police. It has been estimated that only 10–50% of the rapes that actually occur are ever reported to authorities. Since most previous rape studies have selected samples from official sources, hidden victims have been overlooked. The goals of the present study were to describe the victimization experienced by hidden victims and to determine whether any psychological variables were related to victimization status. The psychological variables examined included personality, attitudinal, and situational characteristics relevant to the three major models of rape victimization: social control, victim precipitation, and situational blame. Subjects were 82 not sexually victimized, 37 low sexually victimized, 50 moderately victimized, and 62 highly sexually victimized women. Subjects completed questionnaires and participated in a one-to-one standardized interview. Data were analyzed via multivariate analysis of variance. Personality variables and attitudes did not differentiate the groups of women, while numerous situational variables did. The theoretical implications of these findings are discussed.
Article
Can knowing whether an adult client was abused as a child assist psychologists when assessing suicidality? Reviewing the files of 200 outpatients revealed, in keeping with previous studies, that child abuse was related not only to previous psychiatric admissions and younger age at first treatment and first admission, but also to past and present suicidality. Current suicidality was predicted better by child sexual abuse (experienced on average 20 years previously) than by a current diagnosis of depression. Evidence that abuse histories are not routinely taken, and recommendations for why, and how, taking abuse histories should be integrated into suicide assessment and treatment, are presented.
Article
Subscribers to the medical model of the causation of madness and distress emphasise the role of genes and can severely underestimate the impact of traumatic events on the development of the human mind. This bias persists despite the worldwide popular wisdom that mental illness arises when bad things happen to people. Childhood physical and sexual abuse and neglect are extremely common experiences among those who develop serious mental health problems. Unfortunately, victims are typically reluctant to disclose their histories of abuse and practitioners are often reluctant to seek it. We explore the nature and extent of the problem and the apparent reasons for the pervasive neglect of this important area of care. Then, on the basis of our experience in New Zealand, we provide guidelines on asking patients about childhood abuse and describe an ongoing initiative in the UK to further advance our understanding of the impact of abuse and our skills to detect it and treat survivors.
Article
Psychologists are frequently faced with issues of whether, when, and how to ask clients if they have been abused. Despite the demonstrated relationship between child abuse and adult psychopathology, researchers report that many clinicians still do not routinely inquire about abuse. A questionnaire completed by 63 psychologists and 51 psychiatrists in New Zealand revealed that factors related to reluctance to ask about abuse include the following: more pressing issues, fear of disturbing clients, a diagnosis of schizophrenia, biological etiology beliefs, and fear of inducing "false memories." Significant differences were found between psychologists and psychiatrists on some of these factors. Practice guidelines for enhancing the frequency and efficacy of abuse inquiry are presented.
Article
In the context of studies finding low levels of enquiry about abuse by clinicians in the U.S.A. and the U.K., the medical records of 200 consecutive adult clients of a New Zealand Community Mental Health Centre were reviewed. All information regarding clients' abuse histories contained within the files was noted. The results suggest that enquiry about abuse is not routinely taking place. Assessments conducted using a form with an abuse section identified significantly greater prevalence rates of abuse than assessments conducted without the form. When notes in the current chart from previous contacts with mental health services were included, a prevalence rate of 46% for childhood and/or adulthood abuse was calculated. Only approximately half of this abuse, however, was identified in the notes of the current admission. Recommendations are proposed regarding the need for unit policies ensuring routine enquiry about abuse in standardised admission procedures, and for providing clinicians with training in how and when to enquire about abuse, and how to respond.
Article
This literature review examines the extent to which mental health professionals enquire about childhood sexual abuse during routine mental health assessments in acute mental health settings. Five electronic databases were searched for papers which explored the nature of enquiry about childhood sexual abuse by mental health professionals. The literature was searched between December 2008 and March 2010, with an update in October 2011. Of the 332 papers identified, 54 papers were selected as potentially relevant and data extraction was performed. Eleven studies met the inclusion criteria. Eleven studies were identified that either examined the prevalence of childhood sexual abuse enquiry documented in medical records, or directly asked mental health professionals about their own practice in relation to this subject. The studies found that while many professionals acknowledged the importance of enquiry, there was little evidence of widespread routine enquiry during mental health assessments in acute settings. Mental health professionals do not routinely enquire about childhood sexual abuse during mental health assessment in acute mental health settings. Service providers may have to consider incorporating mandatory enquiry into mental health assessments.
Article
A prospective methodology was used to explore predictors of sexual assault disclosure among college women, identify who women tell about sexual victimization, and examine the responses of informal support providers (N = 374). Women most often confided in a female peer. Increased coping via seeking emotional support, strong attachments, and high tendency to disclose stressful information predicted adolescent sexual assault disclosure and disclosure over the 7-month interim. Less acquaintance with the perpetrator predicted disclosure over the follow-up, including experiences of revictimization. Victim and perpetrator alcohol use at the time of the assault also predicted disclosure over the follow-up. Implications are presented.
Article
In a two stage retrospective survey on child sexual abuse (CSA), a majority of CSA incidents were reported at both postal and interview stages of the survey. Incidents that involved genital contact were most likely to be reported at both stages. A significant number of women reported abuse by a close family member in the postal questionnaire but not at interview. In contrast, incidents mentioned only at interview were more likely to be carried out by a stranger. At interview, many women who replied negatively to a general screening question on CSA went on to report abuse in response to detailed descriptive questions. This was especially true for noncontact experiences. Increasingly restrictive definitions of CSA lowered the prevalence rate for CSA under the age of 16 years from 34.4% to 19.7%. The implication of these findings for the design of future studies is discussed.
Article
The literature suggests that a high prevalence of a history of sexual and physical abuse among psychiatric inpatients is found when researchers inquire about abuse directly, but that relatively low rates are found in medical records. This study examined rates of reported abuse among patients who were and were not asked about abuse at admission. The medical records of 100 consecutive admissions to an urban general hospital in New Zealand were examined after the introduction of a new admission form with a section inquiring about abuse. Use of the new admission form was recommended but not mandatory. The abuse section of the new form was completed for only 17 of the 53 patients with whom the new form was used. Review of the medical records of all 100 consecutive admissions revealed a prevalence rate of 32 percent for one or more of the four types of abuse. However, 14 of the 17 patients (82 percent) who were asked directly about abuse reported having experienced abuse. Nonsignificant trends suggested that male gender and being more disturbed or disturbing may be negatively related to the probability of being asked about abuse. Men may be particularly unlikely to disclose childhood abuse if not asked directly. The authors recommend including inquiry about abuse in standardized admission procedures and providing inpatient staff with training in how and when to ask patients about abuse and how to effectively follow up affirmative responses.
Article
Published protocols for forensic interviewing for child sexual abuse do not include specific questions about what prompted children to tell about sexual abuse or what made them wait to tell. We, therefore, aimed to: (1) add direct inquiry about the process of a child's disclosure to a forensic interview protocol; (2) determine if children will, in fact, discuss the process that led them to tell about sexual abuse; and (3) describe the factors that children identify as either having led them to tell about sexual abuse or caused them to delay a disclosure. Forensic interviewers were asked to incorporate questions about telling into an existing forensic interview protocol. Over a 1-year period, 191 consecutive forensic interviews of child sexual abuse victims aged 3-18 years old in which children spoke about the reasons they told about abuse or waited to tell about abuse were reviewed. Interview content related to the children's reasons for telling or for waiting to tell about abuse was extracted and analyzed using a qualitative methodology in order to capture themes directly from the children's words. Forensic interviewers asked children about how they came to tell about sexual abuse and if children waited to tell about abuse, and the children gave specific answers to these questions. The reasons children identified for why they chose to tell were classified into three domains: (1) disclosure as a result of internal stimuli (e.g., the child had nightmares), (2) disclosure facilitated by outside influences (e.g., the child was questioned), and (3) disclosure due to direct evidence of abuse (e.g., the child's abuse was witnessed). The barriers to disclosure identified by the children were categorized into five groups: (1) threats made by the perpetrator (e.g., the child was told (s)he would get in trouble if (s)he told), (2) fears (e.g., the child was afraid something bad would happen if (s)he told), (3) lack of opportunity (e.g., the child felt the opportunity to disclose never presented), (4) lack of understanding (e.g., the child failed to recognize abusive behavior as unacceptable), and (5) relationship with the perpetrator (e.g., the child thought the perpetrator was a friend). Specific reasons that individual children identify for why they told and why they waited to tell about sexual abuse can be obtained by direct inquiry during forensic interviews for suspected child sexual abuse. When asked, children identified the first person they told and offered varied and specific reasons for why they told and why they waited to tell about sexual abuse. Understanding why children disclose their abuse and why they wait to disclose will assist both professionals and families. Investigators and those who care for sexually abused children will gain insight into the specific barrier that the sexually abused child overcame to disclose. Prosecutors will be able to use this information to explain to juries why the child may have delayed his or her disclosure. Parents who struggle to understand why their child disclosed to someone else or waited to disclose will have a better understanding of their child's decisions.