Services for victim/survivors of sexual assault

Identifying needs, interventions and provision of services in Australia
ACSSA Issues No. 6 – December 2006

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Specialist sexual assault services in Australia: The existing research

Little research has been conducted into therapeutic approaches or interventions with survivors in Australia and what there is tends to be descriptive in nature. No studies could be identified in the Australian literature that focused on the reduction of symptoms linked to specific psychological disorders using experimental or quasi-experimental designs. Some of the research that has been conducted does identify what survivors perceive to be emotionally helpful versus unhelpful about the services they have accessed. Before discussing this, a background to the sexual assault services sector in Australia is provided.

Historical background to Australian services

Efforts to draw public attention to the importance of violence in the lives and health of Australian women were critically connected to second wave feminism (Weeks, 1994). Violence against women was made a priority area for focus at the first Women's Liberation Conference held in Melbourne in 1970. The first Rape Crisis Centres were established in Sydney and Melbourne in 1974. The Melbourne Rape Crisis Centre was run by Women Against Rape at the Women's Liberation Centre in Melbourne with medical services provided by the Melbourne Women's Health Collective in Collingwood. The Queen Victoria Hospital started providing gynecological check-ups and counselling to recent victims of sexual assault in 1977 and the Geelong Rape Crisis Centre was started in 1978. These early services came into being as a direct result of activism by grassroots women's health groups who shared a passionate interest in what was then called 'women's liberation'.

The first services were run as collectives and relied on the work of highly committed volunteers. They were informed philosophically by feminist analyses of society that attributed sexual violence to a patriarchal social order. Women who gave their time to run the early services were initially loath to consider government funding because of the belief that such funding would have unpalatable strings attached, encourage cooption, weaken women's control over services and dilute their agenda of radical social change and emphasis on the prevention of sexual violence (Broom, 1991; Hewitt & Worth, n.d.; Weeks, 1994). Male control of social institutions such as the criminal justice system and the low rate of conviction of men for crimes of sexual violence were seen to illustrate the way in which patriarchy served the interests of men while denying legitimacy to the interests and concerns of women and blocking women's access to justice, power and resources.

The number of funded services increased after the Whitlam Government came to power in 1972. Its platform of social change was more compatible with the philosophical views espoused by the feminists who had set up the first women's health and sexual violence services. A seminal publication that further galvanised women's activism around rape was Against our will: Men, women and rape by Susan Brownmiller published in 1975. The first funded Sexual Assault Centre, at Melbourne's Queen Victoria Medical Centre, began in 1979. It was not until the late 1980s that a significant number of government-funded Centres Against Sexual Assault (CASAs) and other Centres that shared the same philosophy of service provision (but have somewhat different names) began to be set up throughout Australia.

Some 118 sexual violence services were identified as potential participants by the National Association of Services against Sexual Violence (NASASV) by the time the National Data Collection Project on these services and their clients was undertaken by NASASV in 2000. These services continue to be informed by feminist notions of practice and situate the crime of sexual violence as an abuse of rights, particularly the rights of women and children (NASASV, 2000).

Research on Australian sexual assault services and on 'mainstream' health services that see the vast majority of sexually victimised women is extremely limited, and presented here below.

Data on services

The main source of information on services for survivors comes from the National Data Collection Project undertaken in 2000 by the National Association of Services against Sexual Violence. These services, in keeping with their feminist principles and rights based perspective, prioritise service users' rights to informed consent, information, confidentiality and respectful responses. Many place a priority on violence prevention programs and campaigns and aim to "enhance community understanding of sexual violence against women and children by countering myths with current and comprehensive data" (NASASV, 2000, p. 1).

The objective of the Project was to gain information from all 118 services identified as eligible to participate but unfortunately only 37 services nationwide returned complete evaluation data. This resulted in a participation rate of just over 31%. Nevertheless during the three-week period of data collection in April-May 2000, more than 4,000 contacts with services were recorded and provide a valuable snapshot of services against sexual violence. Most service users (85%) were female and the largest single group (62%) were victim/survivors of sexual assault, followed by professionals (17%). More than half of the contacts were made in person (2,039) followed by phone contacts (1,760) while a small number of people (49) contacted services through writing. Counselling was the most commonly requested service (1,918) followed by information (1,451) and crisis support (639). No information was collected on the length of time service users spent in counselling.

Characteristics of service users

More than 27% of those who contacted sexual assault services were in the age group, 20-29 years, and they comprised the largest group of survivors to contact the services followed by those in the 30-39 age group (22%). The study does not provide data on whether all those who contacted services received the type of service they were seeking.

Indigenous service users

Around 3.5% of service users identified as Indigenous while in the Australian population overall, Indigenous Australians make up only 2%. It would be a mistake, however, to conclude that Indigenous people are high users of sexual violence services. Indigenous Australians as a group are significantly younger than other Australians and younger age is a risk factor for sexual assault. For example, in 2001, the proportion of Indigenous people under 15 years of age was 39% compared with 20% of non-Indigenous persons and the median age of Australia's Indigenous population was 20 years, some 16 years younger than the median age for the non-Indigenous population (36 years) (ABS, 2005).

Service users with a disability

Around 20% of service users indicated that they had a disability of some sort. The largest group (n = 350) however did not specify the nature of their disability. Of those who did specify, a mental health disability was the most common (n = 270).

Characteristics of the sexual assaults experienced by service users

Child sexual assault was the most common form of sexual assault for which services, presumably counselling, was requested. More than 1,100 victim/survivors had sought services for this form of assault during the study. This was followed by rape, for which services were sought by slightly less than 600 victim/survivors.

Sexual assaults mainly occurred in the victim's home (46%) with a further 18% occurring in the perpetrator's home. Twelve per cent of assaults were perpetrated by multiple offenders and most offenders (10%) were known to the victim, with the majority being male (79%).

Relationship of services users to the perpetrator

In line with previous research, the vast majority of victim/survivors knew the person who assaulted them. Given the large number of service users seeking assistance with issues related to child sexual assault, it is not surprising that the largest group of perpetrators identified were parents. They were followed by friends and acquaintances, other family members, trusted adults and step-parents. Ninety six per cent of single perpetrator assaults were reported as male. The majority of offenders were aged between 16 and 49 years.

'No longer silent'

The main source of evidence on service users decision making around help seeking and survivors perceptions, views, and experiences of sexual assault services, is Denise Lievore's (2005) study No longer silent: A study of women's help seeking decisions and service responses to sexual assault.

This qualitative study focused on service users who had experienced adult sexual assault and consisted of two components. The first examined social and personal factors that influenced victim/survivors' decisions to seek help from a variety of sources including sexual assault services. It involved semi-structured interviews with 36 female survivors recruited through sexual assault services across Australia. Service users' views were complemented by 65 sexual assault counsellors representing 23 services. The second component involved consulting with 55 sexual assault workers regarding their perceptions of the efficacy of coordinated service provision, their experiences of collaborating with criminal justice and forensic medical personnel and their recommendations for improving service delivery. We discuss the findings of this study here, including the context of other research on service provision from overseas.

Disclosure, decision-making and social support

The study revealed how sexual assault had affected and disrupted every dimension of survivors' lives. Victim/survivors faced making decisions about a range of important life issues, not just the decision about whether to report sexual assault. Help-seeking decisions involved multiple decision points and were affected by survivors' relationships with people from different social contexts and their reactions to disclosures about sexual assault.

The quality of support survivors received was variable within both formal and informal sources of assistance. Of the formal helping agencies, sexual assault counsellors were the most highly valued. Medical, mental health services and services provided by other organisations were judged as less empathetic and less helpful. Among informal support networks, survivors were more likely to disclose to friends and to find them more helpful than family members. Even when friends or family members wanted to be helpful and supportive, they were often unsure about how to provide this or what to say. Women who lacked informal sources of support and had poor mental or physical health were particularly vulnerable to violence and its effects.

Overseas studies have also found that social support is a critical mediator of mental health outcomes. In a study of more than 300 survivors Ullman and Filipas (2001) found that women with lower education, whose assaults were characterised by greater threat to life and who received more negative social reactions on disclosing adult sexual assault, had more severe symptoms of PTSD. Conversely, survivors who had someone believe their account of what happened or were allowed to talk about the assault and considered these reactions to be healing had fewer physical and emotional health problems (Campbell, Ahrens, Sefl, Wasco, & Barnes, 2001). Social support also moderates long-term mental health outcomes (Murthi & Espelage, 2005).

Service users' perspectives on disclosure

Of the 36 service users interviewed in Lievore's study, slightly more than three quarters knew their perpetrator and slightly fewer than half of the women first disclosed the sexual assault to a friend. Of the remainder, five had disclosed to strangers including neighbours or passers-by. Disclosure to police or a doctor was less common than disclosure to family members, a counsellor or a psychologist. Three patterns of disclosure were identified. These were: unsolicited disclosures (n = 25); solicited disclosures (n = 7); and disclosure in the context of being rescued (n = 4).

The first disclosure of sexual violence was not always a planned action or a conscious decision with a clear objective in mind. Time to disclosure ranged from immediately after the sexual assault to decades after its occurrence. Disclosure and help-seeking were largely determined by the context of the sexual assault and/or the social context that made disclosure possible. Other people's confirmation that a serious crime had occurred coupled with an offer of support was instrumental in persuading many survivors to report to police. Unlike the majority of survivors, most of the participants in Lievore's study reported the offence to police. Only six of the 36 women did not report to police. Of the women who did report, 17 reported on their own behalf and 13 had reports made for them by other people. Despite the high percentage of women who reported to police, most reported concerns or negative perceptions about becoming involved in the criminal justice process.

Common threads in the narratives of the participants around their needs at the time of disclosure included the need for safety and protection, emotional or medical help in crisis whether this was months or years after the assault, emotional support and being believed by someone who was sympathetic, not being blamed, making sense of what had happened and having their experiences validated. Needs specifically related to the time when the sexual assault occurred included medical help and practical help such as getting to the police or accessing advice on available options.

It is believed by many researchers and practitioners that in order to be able to deal with and overcome the trauma of sexual assault, it is necessary to name unwanted sexual experiences as sexual assault. A quarter of the women interviewed did not or could not do so even though all of these women had experienced serious psychological and physical consequences, ranging from depression and suicide attempts to poor health and eating disorders.

Lievore (2005) commented that this finding is consistent with previous research about the naming of sexual assault. For example, one early study (Koss & Gidycz, 1985) found that 43% of women who said 'yes' to questions about sexual assaults that met the legal definition of rape, answered 'no' to the question, 'Have you ever been raped?' Part of the difficulty in naming sexual assault may derive from the fact that the efforts, cognitive and emotional, that women make to cope with and contain the distress associated with sexual violence, may also minimise perceptions of its severity. Kelly's (1998) argument cited by Lievore is somewhat different although not necessarily incompatible with this and centres on the silencing of women by dominant male discourses that limit what "is deemed unacceptable (sexual behaviour) to the most extreme, gross and public forms" (Kelly, 1988). Lievore (2005) contended that "this process of silencing occurs from the macro level of social discourses and representations, including discourses around women's lack of entitlement to sexual autonomy or stereotypical media representations of 'real rape' through to the micro level of interpersonal interactions" (p. 32).

As noted earlier, participants rated sexual assault counsellors as their most valued source of support but at the same time all participants were recruited through sexual assault services suggesting the possibility of selection bias. A few women in Lievore's study did express dissatisfaction with these services but most made highly favourable comments about their counsellor/advocates including "fundamental to my recovery", "my lifeline", "amazing" and "my lifesaver".

Sexual assault services provide a context that functions as an antidote to the culture of censorship and silence that victims can experience in the wider society. Participants' comments underline how psychologically powerful it was to be able to talk and freely express their emotions about what had happened to them and to be believed.

The following comments were from participants in Lievore's (2005) study:

I needed to talk to just get stuff off my chest, I needed to cry, because I held it in, even with my best friend. (Annabelle, p. 67)

I let everything out and that helped put things in perspective. (Alison, p. 67)

It was helpful to talk about anything and everything to the counsellors. (Michelle, p. 67)

This benefit also characterised group work, where the ability to talk with other women was combined with having a sense of belonging at a time when most women's capacity to trust had been violated and they felt profoundly isolated.

I enjoyed group therapy, it was really good meeting women in the same situation. They were as close as I had to friends. I didn't want friends because I didn't trust people. (Kate, p. 68)

Besides group therapy, women valued many other types of activities that occurred in groups such as art therapy and yoga as well as being given brochures on relaxation, tips on how to sleep, information on self-defence and anger management, being able to borrow books on relevant subjects such as relationships and abuse and receiving practical assistance such as help with letters about compensation. These and other activities 'value-add' to standard therapeutic approaches. Moreover, techniques for stress management, weight control, smoking cessation and increasing physical exercise have proven benefits to mood, depression and anxiety levels (Resnick et al., 1997). Sharing information on these techniques with victim/survivors can contribute to the overall goal of healing, namely, by helping to restore power and control to the victimised woman over her life and health.

This approach accords with Herman's (1992) view that violent victimisation is damaging psychologically primarily because it robs the victim of a sense of power and control and is congruent with the feminist, rights-based philosophy of sexual assault services.

Lievore's (2005) study revealed that many of the elements perceived by participants to contribute to the "helpfulness" of services, satisfied survivors' needs for psychological safety. Being able to speak freely to counsellors who understood the effects of sexual violence, were understanding, compassionate and non judgemental, provided emotional support, information, a sense of belonging and ran a service that was accessible at all times, were all thought to be important in "putting things in perspective" and "getting through the process" (p. 67).

Amanda, another participant from Lievore's (2005) study, said:

It's helpful being able to pour your heart out in confidential surroundings, where you're safe and it's okay to ask about your fears. (p. 67)

The establishment of safety represents the first stage in the healing process when feelings of being unsafe extend to the external environment, the perpetrator and women's sense of being unsafe in their own bodies (Herman, 1992). Stage two involves remembrance and mourning and the third stage relates to reconnection with ordinary life. Herman (1992) cautions that stages "are an attempt to impose simplicity and order upon a process that is inherently turbulent and complex" (p. 155). Nevertheless, the idea of stages has utility for sexual assault workers and other health professionals in suggesting the likely preoccupations and needs of victim/survivors at different points in the healing process. Unfortunately, it is not possible to examine the responses of the participants in Lievore's (2005) study regarding what they found helpful in service provision according to Herman's model of stages, due to insufficient data.

Research on the help-seeking patterns of adult survivors of child sexual abuse and their perceptions of what has been helpful versus unhelpful in their attempts to seek meaningful assistance is needed to complement the research undertaken by Lievore with survivors of adult sexual assault. For example, while the research with survivors of adult sexual assault indicated that most women believed that their needs on initial disclosure had been met, it is not known whether the same would be true for survivors of child sexual assault. The greater vulnerability of children, their higher likelihood of experiencing protracted periods of abuse at the hands of adults in positions of trust and their difficulty in accessing services, all suggest that their experiences of disclosure might be more problematic than is the case with adult survivors.

Sexual assault workers' views on models of service provision

The sexual assault workers consulted in Lievore's study endorsed a model of service provision that incorporated a coordinated response to sexual assault involving interagency collaboration between all agencies with whom victims of sexual assault might have contact including criminal justice agencies, forensic services, health and sexual assault services. For a detailed overview of health sector and interagency protocols, see the detailed overview by Olle (2005) in a previous ACSSA Issues paper.

The ideal of full interagency collaboration has not yet been achieved. Of the 14 sexual assault centres consulted in Lievore's (2005) study, only nine were covered by interagency protocols. Workers in the centres were generally optimistic that progress was being made but a number commented on the sources of tension that can arise between personnel working in different agencies and carrying out different and sometimes contradictory roles. Further research is needed to explore how the existing barriers to the full implementation of integrated service models can best be dismantled.

As one worker in Lievore's (2005) study put it:

The process often works well and when it does it's great, but there are glitches, which are mainly to do with different roles and attitudes. We provide support, advocate for the victim/survivor, have an attitude of belief and are focused on client wellbeing. We define a recent sexual assault as occurring within the last two weeks. We go through the survivor's options face to face: we explain about reporting; that she can contact police if she wants to, or just meet with them; we'll go with her to the crisis care unit. This can conflict with the role of other services. The police are focused on investigating the crime and collecting evidence. They talk about the 'alleged' offender and define a recent sexual assault as up to 72 hours. They might not attend the crisis care unit. The police look at it from the view of court processes and the paper work involved. So there's a different language, a different belief system (p. 137).

Workers made several recommendations for promoting organisational change and improving social responses to sexual assault. They recommended dismantling barriers to accessing sexual assault services, increasing support for sexual assault centres and specialised service providers, providing specialised training for all systems dealing with marginalised groups and collecting reliable statistical data on sexual assault among women with disabilities and from Indigenous and non-English speaking backgrounds. For a full discussion of sexual assault workers' views on service provision, see Chapter 14 of Lievore's (2005) report.

Most participants in Lievore's study held sexual assault services in high regard. Further research is needed to identify the precise mental health outcomes associated with the feminist, rights based approach to counselling used by these services.

Innovations in service provision in Australia

Shared counselling

The only attempt to describe a therapeutic approach used within a sexual assault service that could be located was a small pilot study on Shared Counselling undertaken in 2005 by CASA House in Melbourne. Shared counselling provides an alternative to one-to-one counselling, decentres the therapist and uses outsider witnesses who engage each other in conversations about what is heard in counselling. By using a narrative, feminist perspective, the shared counselling approach reflected a commitment to "validate women's voices and their stories in the face of inequality" (White, 1995).

Three women, all of whom were survivors of child sexual assault, participated in the program and were interviewed pre-counselling, at six weeks and after completion of the program. At the final evaluation, two women gave shared counselling the maximum rating of five and the third gave it a rating of four. The experience of not being alone, hearing the stories of others and seeing how these resonated in their own lives were all highly valued.

One participant described how shared counselling made her "feel special and strong enough to be at ease" (White, 1995, p. 6). For another, identifying the grief she felt helped her to understand "where" she was in herself. Another came to the new belief that there was, after all, a place in the world for her. The women changed how they felt about themselves. Day to day life became less of a struggle. Moments of strength and clarity occurred, relationships and sleep improved and there was "less noise and confusion in my head" and less anger. Sexual assault was no longer seen as being their fault.

The shared counselling approach appears to support existential changes that empowered the women to feel on more solid ground within themselves and as such differs quite markedly from the symptom reduction approach that characterise most of the interventions described earlier. A much larger study of the impact of shared counselling is needed.

Rape Crisis Online

The NSW Rape Crisis Centre established a new service, Rape Crisis Online, in December 2005. The service provides a person-to-person, on-line, real-time information and support service for anyone who has been sexually assaulted and is the first of its kind. Targeted at young people, the service responds to the finding that many survivors of sexual assault report that the most difficult thing after the assault, is telling what has happened for the first time. Advantages of this approach as a first contact with services include survivors being able to access help from a quiet, private location, being able to type words rather than say them and being able to access instant support and information backed up by a website (NSW Rape Crisis Centre, 2005).

Information on the first seven months of operation provided by Jacqueline Burke, Counselling Coordinator at the NSW Rape Crisis Centre, indicates that a total of 149 online contacts were made by 93 individual people to Rape Crisis Online up to July 31, 2006. Around a third had never spoken to anyone before about the violence. The majority (64%) were aged between 16 and 34 years, with approximately 30% from rural NSW. Callers were encouraged to make contact with the NSW Rape Crisis Centre and over a third made subsequent telephone contact. For those who did not want to make contact, counsellors suggested other options.

In line with Lievore's (2005) finding, 30% of callers did not talk directly about being assaulted but asked questions such as "if someone did … to me, is that sexual assault?". The language and content of most of these calls indicated that the authors were young and wanting help but were unsure of the outcome of 'telling'. Of the callers who spoke directly of sexual violence, 30% had been assaulted in the past seven days and 50% had been assaulted six months or more ago. Overall, 40% had been sexually assaulted as adults, 30% had been assaulted when they were children and a few had been gang raped. On line contacts followed the same pattern as telephone contacts with 68% of calls being received between 3 pm and 11 pm.