Patricia Taimanglo , Ph.D. Lilli Perez, Ph.D. Rosemarie Camacho, M.A .

1. Healing the Wounds of Sexual Assault: Practical Strategies for Working with Victims Across the Lifespan SAARCA Guam Sexual Assault and Abuse Resource Center Association Patricia Taimanglo, Ph.D. Lilli Perez, Ph.D. Rosemarie Camacho, M.A.

2. Acknowledgements • Guam Sexual Assault and Abuse Resource Center Association (SAARCA) • Funding from Governor’s Community Outreach Federal Programs Office • Ellen Bez, M.D. • Attended APSAC conference in July 2011 • Project Karinu • supported Dr. Perez’s attendance • Healing Hearts Crisis Center • Local statistics • AIMFT • Wayne Butler • registration • University of Guam: • Joan Swadell • facility

3. The American Professional Society on the Abuse of Children 19th Annual Colloquium Philadelphia, PA July 13-16, 2011

4. APSAC 19th Annual Colloquium • 93 institutes and workshops which addressed all aspects of child maltreatment: • prevention, assessment, intervention • treatment with victims, perpetrators and families affected by physical, sexual and psychological abuse and neglect • Cultural considerations

5. APSAC 19th Annual Colloquium • Seminars designed primarily for professionals in: • mental health, medicine and nursing, law, law enforcement, education, prevention, research, advocacy, child protection services, and allied fields • Educational goal: • foster professional excellence in the field of child maltreatment by providing interdisciplinary professional education

7. Background • Dr. Taimanglo, Clinical Psychologist • DMHSA • Private Practice • Dr. Lilli Perez, Clinical Director, Project Kirinu • Private Practice • Rosemarie Camacho, IMFT • Substance Abuse Counselor

8. Background • ALL have been providing individual and family therapy to victims of sexual assault for at least five years • Healing Hearts Crisis Center • Clients who come in due to other concerns • but have history of sexual assault • e.g. dual diagnosis of substance abuse and PTSD due to sexual assault

9. Agenda • Local Statistics on Sexual Assault • serves as a backdrop for all three presentations • most clients we see were victimized as children • Dr. Perez will cover working with children • Rosemarie will cover working with adolescents • Dr. Taimanglo will cover working with adults

10. Agenda We will each cover: • general assessment of the experience • not assessment tools • not forensic interviewing • therapeutic techniques used in practice • based on training and experience working with victims • Knowledge, skills, techniques learned at the conference • emphasis on culturally relevant application • Experiential activities • FUN!

11. Timeline: 1:00 – 1:15: Introduction and Local Statistics 1:15 – 2:15:  Dr. Perez - Children 2:15 – 2:25: Break 2:25 – 3:15: Rosemarie Camacho – Adolescents 3:15 – 3:45: Dr. Taimanglo - Adults 3:45 – 4:00 Question and Answers

12. Local Statistics on Sexual Assault Who are the victims? Who are the perpetrators? Healing Hearts Crisis Center

13. Age groups for 2004 - 2008

14. Healing Hearts Clients 2004-2008

15. Minors: Population 2009-2010

16. Gender Served 2009 - 2010

17. Ethnicity of victims for 2008

18. Population by Ethnicity for 2009

19. Population by Ethnicity for 2010

20. Relationship to Offender (2008)

21. Relationship to Offender

22. Relationship To Offender 2009-2010

23. WORKING WITH ADOLESCENT VICTIMS OF SEXUAL ASSAULT Rosemarie B. Camacho, M.A., IMFT

24. Working with Adolescents • Adolescents can be anywhere from 11 to 21 years • Varying degrees of physical/emotional/intellectual maturity • dictates whether to us child/adolescent/adult resources and materials • usually “round up”

25. Working with Adolescents • Most were abused as children somewhere between 7 and 13 • Many referred to school counselor and/or DMHSA for cutting and/or suicidal ideations, then disclose childhood sexual abuse • e.g. 14 year old Chamorro girl referred to school counselor for cutting, then discloses being abused by older cousin when she was between 9 and 11

26. What happened? How has it affected the client? How has it affected family? Assessment

27. Parent Interview • Begin with Parent Interview • Victim may not even come to the 1st appointment • or may meet for a few minutes at the end • Parent Interview may take up part of the second session • Helps the client get comfortable • Psychosocial Interview • Medical Concerns • Family Structure • School performance • Any known self-harm behaviors

28. Parent Interview • Discuss privacy • Mandatory reporting requirements • Child’s privacy • Reasonable degree • Importance of trusting relationship • Will share any concerns of potential danger • Ongoing Drug Use • Illegal Behaviors • Inappropriate relationship

29. Parent Interview • Strengths • When does he/she seem the happiest, the most calm, relaxed? • #1 answer . . . • When she’s with her friends • If behavioral concerns . . . When is she the most respectful, responsible, etc.? • #1 answer: • When she wants something!

30. Parent Interview • Goals • How will we know when things are better? • When she’s more open, smiling more • When she’s more respectful, more responsible • #1 indicator that makes parents happy: • When her grades are up • Others: • Does her chores • Communicates more respectfully • Discuss importance of realistic goals • Put out the “big fires” • Accept normal behaviors among adolescents

31. Parent Interview • What are some of his/her strengths? • that we can build upon to meet our goal • loves to read, listen to music, writing, art, etc. • Hobbies, interests • STRONGLY encourage organized sports, dance, clubs, etc. • Keep life as normal as possible • not punish the victim further • Help to “compartmentalize” • Open up a new chapter • WHO are some strengths in your child’s life • Grandparent, cousins who are doing well, etc.

32. Parent Interview Effects of the assault: • How has this affected your child? • Nightmares, hypervigilance, self-harm, suicidal ideations, withdrawal • Child checklist of characteristics • When (if at all) did you notice a change? • Often in hindsight • Got quiet and sad or angry and defensive • easily agitated • withdrew from the family • normalize adolescent behavior

33. Parent Interview Noticable changes: • Often made cryptic remarks, emotional outbursts • “You don’t understand what I’ve been through!” • Often tried to avoid contact with abuser • I hate going over there! • Excessive resistance • E.g. I finally asked her, “Did something happen, did someone touch you? and she just started to cry. and that’s when I knew”

34. Assessment/Psycho-education • General Assessment of the victimization and resulting experience • “Assessing the damage” • while also conducting psycho-education/making recommendations about what can make the experience less or more traumatizing • aka “buffers” 1) Physical aspects of the assault • severity: mild-moderate-severe • E.g., force or penetration vs. exposure to pornography • single incident vs. multiple incidents • WHERE did the assault take place? • Victim’s home? • sometimes recommend changing rooms or re-decorating

35. Assessment/Psychoeducation 2) Relationship of perpetrator to victim • parent/caregiver vs. stranger or acquaintance • How emotionally close? • favorite uncle, older cousin who was like a brother, etc. • Closer the relationship, the more traumatizing • Incest cases often most damaging • but also depends on other “buffers” • Case example: teenage girl forced into incestuous relationship with biological father that she met at13 years old. • Very positive outcomes

36. Assessment/Psychoeducation • First two are “fixed” • what happened, who did it? • “What’s done is done” • Able to guesstimate whether client will need short-term or long term therapy • combined with psychosocial interview • Other traumatic experiences • Strengths • Social support network • Next factors include parent recommendations • crucial in the healing process

37. Assessment/Psychoeducation • 3) Emotional Support • Does the parent believe and support the child? • Caution against “blaming victim” for not telling, etc. • Do other family members and friends believe and support the child? • Easy when abuser is a stranger • more complicated when it’s a family member • e.g. 14 year old girl abused by mother’s boyfriend • brought by grandparent who has temporary guardianship because mother doesn’t believe her and is still in a relationship with the abuser • worse when parent believes sexual contact occurred but blames the child for provoking it

38. Assessment/Psychoeducation • “Ripple Effect” of disclosure is often more traumatizing than the abuse itself • e.g. 11 year old girl abused by 17 year old cousin while they were at grandparents’ house. Was very close with abuser’s 12 year old sister, but now she is not talking to victim because she “put their brother in jail” • de-friended on Facebook • putting cryptic messages on her wall • Mom and her sister (abuser’s mother) are no longer speaking, etc. • Grandma’s is crying, doesn’t know who to believe

39. Assessment/Psychoeducation • “Ripple Effect” • broken relationships • moving around • changing schools • family Conflict • Victim always feels responsible for the “ripple effect” • Often regrets telling • Often the cause for recantations • didn’t mean to break up the family • Emphasis on “Who threw the rock?”

40. Assessment/Psychoeducation 4) Sense of Justice (related to emotional support) • Focus of anger, blame appropriately placed on perpetrator • Perpetrator held accountable • legally • Jail time, mandatory counseling, etc. • socially • Ostracized from the family • “karma” • “Ti mamaigosiYu’os”

41. Treatment

42. Treatment Healing Heats Crisis Center • 6 sessions including Parent Interview • Request extension, as needed • majority need more than 6 Normalization • You’re not alone • 1 in 3 girls are abused by the time they are 18 • “count off in PE”

43. Treatment • Analogy of Boil/Abscess • Ask about any scars they have • Tell me how you got that scar • Does it hurt now? • You never forget how you got the scar, but it doesn’t hurt anymore • All traumatic experiences are like an open wound until you heal • Difference between a wound and a boil • Grandpa died: like breaking your arm • Not ashamed of the wound, not afraid to seek support

44. Treatment • Sexual abuse: Boil/Abscess • Hide the wound, ashamed of it, feel dirty • Try to treat it yourself, but it just keeps getting worse, infected • Every day bumps and touches hurt • Treatment: Hibiscus Flower or Warm Compress • Treat it gently, get the infection out • It gets ugly, gross, but then heals • Leaves a scar for a while • Harry Potter scar • stings from time to time

45. Treatment Juvenile Interview: • Establishing Rapport, Trust, Comfort • Similar to parent interview • What do people like about you? • What might some people not like about you? • What do you like about each member of your family? • What do you wish was different about each of them? • Same question for friends • Drugs and alcohol (rarely reported) • Other sexual experiences (rarely reported)

46. Treatment • Traumatic Screening: 3 most difficult experiences • Sexual Assault may not be the most traumatizing • Ripple effect often more traumatizing • 3 Best Experiences: • Best things that have happened to you • Accomplishments you are most proud of • Suicidal Ideations – Scale of 0-10 • 0-5 – thoughts with no intent • 6 increasing thoughts of intent – when, where, how

47. Treatment Primary Resource: It Happened to Me: A Teen’s Guide to Overcoming Sexual Abuse • Approximately 50 exercises • Includes writings by adolescent survivors • Utilize between 4 and 6 • 1-2 per session

48. Treatment 1. Your Feelings - What do they mean? • Normalization of reactions to sexual abuse • Confusion, shock, guilt, paranoid, disgust, denial, anger, shame, nausea, betrayal, fear • Usually see a sigh of relief or moment of realization that they are not alone • Which emotions did you experience at the time of the abuse? • Looking back, when did you first start to feel uncomfortable? • Body/Mind warning system • Healthy Boundaries:  Going with your gut! • Which did you experience immediately after? • Which do you still experience now?

49. Treatment 2: Family Messages • Usually if the abuser is a family member • My Mother/Father always says . . . • “Family is more important than anything else” • “Don’t shame the family” • Cultural beliefs, value of interdependence • Sacrifice personal needs for family needs • Messages about girls and boys • “Nice girls stay quiet” • “Do what your brother says” • Family messages I would like to pass on . . . • Family messages I would like to throw away . . .

50. Treatment 2: Family Messages (continued) • Messages about children and adults • “Respect your elders!” • In each category, ask about the messages they received and how it affected the experience • ability to resist or speak up • Often blame self for letting it happen • or not reporting sooner • Validate the experience • Work through guilt and learn to let go