Establishing the connection
Guidelines for practitioners and clinicians in the sexual assault and alcohol and other drug sectors
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How to use this guide
These guidelines have been developed to build the capacity of workers in the sexual assault and alcohol and other drug (AOD) sectors in Victoria to support shared clients who experience both sexual assault trauma and substance use issues.
The guidelines have been prepared by the Australian Institute of Family Studies in partnership with CASA Forum and UnitingCare ReGen. They are the result of an Australia's National Research Organisation for Women's Safety (ANROWS) funded project exploring the enablers and barriers of the AOD and sexual assault sectors in referring shared clients to specialist services.
There are links to relevant information provided throughout this resource, and we encourage you to interact with your local sexual assault/AOD service and promote interagency training and collaboration in support of your shared clients.
These guidelines can be applied and adapted throughout Australia.
- Sexual assault and alcohol and other drug use have a complex association, and supporting clients with co-occurring sexual assault trauma and AOD use is the core business of your service (see Resources).
- Ask a client about their sexual assault trauma history.
- Ask a client about their substance use.
- If a client is ambivalent about accessing another service, consider a secondary consultation to support you in keeping the client stable (if necessary) and safe.
- Facilitate access to specialist sexual assault/AOD services via referrals.
- Consider giving your local sexual assault/AOD service a call and introducing yourself. Building relationships can support service delivery to vulnerable clients.
- Investigate training opportunities between sexual assault and AOD services via your organisational supervisors.
- Practice effective self-care (see Resources).
Sexual assault and substance use: What's the connection?
Some research shows that while people who have experienced sexual assault may drink or use drugs to cope with their negative emotions (predicated by the distress coping model), they may also do so to enhance their positive emotions (the emotion regulation model) (Grayson & Nolen-Hoeksema, 2005). Broadly, this research is seen as supporting the "self-medication" theory, in which individuals are thought to use alcohol and other drugs to "dampen" or turn the dial down on the intense feelings of distress, anger, fear and anxiety associated with their traumatic experiences (Darke, 2013; Miranda, Meyerson, Long Marx, & Simpson, 2002). However, it is worth exercising caution in the use of the "self-medication" phrase, which runs the risk of seeing the functional role of substance misuse as a deficiency on the part of survivors rather than a coping strategy that enables survival (Breckenridge, Salter, & Shaw, 2012), or of assuming the functional role is the same for all survivors.
Qualitative research undertaken with survivors of sexual assault demonstrates that although there are common reasons for using alcohol and other drugs, such as numbing and managing emotions, the context of their daily lives helps to further understand the relationship between sexual assault and substance misuse. For example, substances may be used to manage nightmares and sleep patterns (Breckenridge et al., 2012), to keep memories and flashbacks at bay in chronically unsafe or unstable situations (Padgett, Hawkins, Abrams, & Davis, 2006), or to minimise trigger and startle responses that can make victims feel the world is unpredictable.
Prevalence of and relationship between sexual assault and AOD use
Sexual assault prevalence and other statistics
- Seventeen per cent of all Australian women and 4% of all Australian men reported having experienced sexual assault since the age of 15 (Australian Bureau of Statistics [ABS], 2013).
- The rates in Australia for penetrative sexual abuse of children were estimated at 1-8% among males, and 4-12% among females (in studies from 2001-10) (Price-Robertson, Bromfield, Vassallo, & Scott, 2013).
- In Victoria, in 2013-14, police recorded 2,177 rape offences (Victoria Police, 2014).
- In Australia, in 2010, police recorded 17,757 sexual assault victims (ABS, 2011).
Alcohol and other drug use prevalence and other statistics
- Five per cent of Australians meet the criteria for having a substance use disorder (Australian Institute of Health and Welfare [AIHW], 2015).
- In Victoria, in 2014, there were more recorded deaths from pharmaceutical drug use than traffic accidents (Whitelaw, 2015).
- In Victoria, between 2000-01 and 2009-10, rates of clients receiving AOD specialist treatment increased by 61% (Matthews, Jayasekara, & Lloyd, 2012).
- In Victoria, between 2000-01 and 2009-10, rates of alcohol-related assaults increased by 26% (Matthews et al., 2012).
Relationship between sexual assault and AOD use
The relationship between sexual assault and adverse outcomes such as problematic substance use, has been an area of increasing understanding in recent decades, and it is now well established that there is a consistent association between the two. Major research studies include:
- An Australian study of 5,995 twin pairs (with 6% of the women and 3% of the men reporting a child sexual abuse history), found a correlation between child sexual abuse and depression, panic disorders and substance use (Dinwiddie et al., 2000).
- An Australian study with 1,911 twin pairs found that the twin who had self-reported a history of child sexual abuse had a significantly increased risk for all adverse psychological outcomes tested, including alcohol dependence (Nelson et al., 2002).
- Forensic medical records of 2,688 sexually abused children whose abuse was recorded between 1964 and 1995 were examined and compared to a matched control group of 2,677 individuals to determine the rate and risk of clinical and personality disorders (Cutajar, Ogloff, & Mullen, 2010). The researchers found child sexual abuse victims had an increased risk for a number of disorders, including problematic substance use.
For more prevalence statistics and analysis of the relationship between sexual assault and AOD use in Australia, see Quadara, Stathopoulos, and Jenkinson (2015).
How to respond
If you are a sexual assault counsellor/advocate, you do not need to counsel clients for AOD use, but if your client does disclose they are having a problem with substance use or they arrive at sessions intoxicated, making it difficult for you to continue to provide support for them, you should:
- be non-judgmental in your response - there can be fear and shame in disclosing substance use, and seeking help can be difficult;
- discuss the possibility of them accessing AOD treatment or having some telephone counselling (which can be in conjunction with sexual assault trauma therapy);
- seek their permission to do a secondary consultation with an AOD counsellor to support them to continue their sexual assault trauma therapy;
- discuss the different types of services available within the AOD treatment system (as outlined in the UnitingCare ReGen's Outline of Our Treatment Services; and
- if the client is ambivalent about seeking treatment or being referred, let them know you will, with their permission, check in with them at a later stage regarding their substance use and how they are coping.
If you are an AOD counsellor or worker, you do not need to counsel clients for sexual abuse trauma, but if your client does disclose they are a victim of sexual assault you can:
- listen - be compassionate and respectful. There can be fear and shame in disclosing, and seeking help can be difficult;
- validate - be non-judgemental;
- believe - the perception that a disclosure is a false allegation has negative consequences for victims of sexual assault, and perpetuates victims' fears of not being believed;
- respond - ensure the person who has experienced sexual assault maintains control over the next step, such as whether they choose to use sexual assault support services (and if they do, you can refer or undertake a secondary consultation); and
- discuss what your client will encounter if they choose to seek sexual assault counselling services.
Referrals and secondary consultations
Providing support and services to clients with a sexual assault history and co-occurring substance use issues is a core activity of AOD and sexual assault services. The following information can support you in focusing on your specialisation while enhancing your capacity to use pathways to refer your clients to other specialist services.
Alcohol and other drug services
The following are the services through which clients may be funnelled, depending on their initial assessment:
- For more information about services, see Alcohol and Other Drug Treatment Services.
- For alcohol and other drug support services and counselling, call ReGen: 1800 700 514 (Monday-Friday, 9 am-5 pm, North and West Metro Victoria).
- For alcohol and drug counselling intake, screening, assessment and referral in Victoria, call DirectLine: 1800 888 236 (24 hours, 7 days a week).
The AOD sector intake process includes the following steps and criteria:
- The telephone intake and screening process may take up to 20 minutes or more. It may take longer if a client chooses to disclose other issues, such as trauma or gambling. If the client feels at the time that the intake and screening process is too onerous, you are welcome to call on their behalf, arrange another session to do this with them, or provide them with the contact numbers so they can call when it's more convenient. You may like to ask their permission to follow up with them.
- Clients will be eligible for AOD service intake if they are:
- at risk of long-term harm or impairment; and
- not able to be assisted by primary health providers alone.
- If the client is not eligible for AOD services, they may still be offered:
- information or advice;
- brief counselling (1-2 sessions);
- six sessions of telephone/online counselling;
- group education programs; and/or
- supported referral to another relevant services (e.g., mental health, housing).
- Your client will be directed to a service in their local catchment area (available from Pathways Into AOD Treatment), but may also choose a treatment provider that operates in a different catchment if they wish. Recent reforms means there is consistency in service delivery across the state.
- If your client meets the criteria, they may be eligible for a number of services, such as detox, residential withdrawal, non-residential withdrawal, counselling, group counselling, forensic counselling, and family counselling. A detailed explanation of each of these, as delivered by UnitingCare ReGen, is available on their treatment web page.
- If client's issues are assessed as "standard", they will be provided with four counselling sessions. If they are assessed as "complex" (with multiple issues and complex needs), they will be provided with 14 sessions.
- If your client is uncertain about whether they would like to undertake AOD treatment, they may like to complete Directline's online self-assessment screening, which will advise their eligibility.
Centres Against Sexual Assault (CASAs)
Sexual Assault Crisis Line (SACL): 1800 806 292
This service provides crisis support and counselling for men, women and children regarding recent or historical sexual abuse. The 1800 phone number will direct callers to their local CASA during business hours and to the SACL telephone counsellors after hours.
Crisis care for a recent sexual assault
Crisis care is available for people who have been sexually assaulted within the past 2 weeks.
Services are usually delivered at a Crisis Care Unit that may be attached to the emergency department of a hospital or as part of a multidisciplinary centre, and include:
- counselling at a time of crisis to normalise trauma responses and lessen the long-term effects;
- providing support and advocacy in making decisions related to legal options, including reporting to police and collecting forensic evidence;
- coordinating responses by police and forensic medical examiners that centres on the needs and wishes of the victim/survivor;
- ensuring that the health and medical needs of the person who has experienced sexual assault are met;
- assessing safety and any protection that might be required; and
- providing referrals to other services as needed.
Intake and assessment
All CASAs have an intake system that provides a gateway into the counselling services. The intake process varies across each service. Generally, the process begins with a phone call and includes an assessment either over the phone and/or face-to-face. Assessments are usually made in relation to current safety, and the effects of sexual assault trauma, mental health, drug and alcohol use and so on. Intake also provides information and assistance to the client about accessing CASA and other regional services.
Referrals by other professionals can be made to CASAs over the telephone. CASAs usually want to talk with the client directly, but will work with referring professionals to provide support. Some professionals will bring the new client along to the first appointment to assist with any concerns or anxieties about coming to a sexual assault support service.
Most CASAs have waiting lists for their counselling services. CASAs make priority allocations for people who are considered vulnerable, such as children and young people, people who have experienced a recent sexual assault, Aboriginal and Torres Strait Islanders, and people exiting prison.
Those not given a priority allocation can wait three or more months for a service. CASAs can provide support to people on waiting lists through the SACL telephone service. Most CASAs will offer one-off "duty" appointments if people need additional support while on the waiting list.
All CASAs will ensure people who use the service are offered additional personal support, such as access to a public advocate, Indigenous representative or other support person with whom they might identify.
Counselling and advocacy
CASAs will see children, young people and adult victims of sexual assault as well as non-offending family members/carers and significant others for counselling.
Services are provided for both men and women and include:
- individual counselling;
- family counselling;
- group work;
- telephone counselling and support; and
- advocacy to assist with access to information, and ensuring their legal and other rights are being met, including referrals to other services.
The number of counselling sessions each CASA offers will vary.
Through their intake service, all CASAs offer secondary consultations to other professionals to support their own work with clients who are also victims of sexual assault. CASAs can also provide training to other services to support their professional capabilities in responding to people who have experienced sexual assault.
Addressing barriers to service provision
There can be obstacles to providing care for clients with complex and co-occurring sexual assault and alcohol and other drug use. Barriers to effective care may include a lack of time and other resources, a lack of clinical experience or confidence, and a perceived lack of pathways to formal interagency coordination and support.
Clients may be reluctant to discuss sexual assault or substance use, and this is okay; however, if there is a possibility for referral and your client does disclose and indicate a desire to engage with other specialist services, your expertise in how to accommodate and guide them might lead to better outcomes.
Strategies may be put in place by sexual assault and AOD treatment services to support professionals in addressing any challenges to service provision.
Strategies for individual professionals that can support clients with co-occurring sexual assault and substance use include:
- understanding the relationship between sexual assault and AOD use;
- being aware that this relationship includes individual, but also relational and social contexts;
- providing a safe environment in which clients may disclose sexual assault and substance use; and
- enabling trust, through non-judgemental engagement.
Organisational strategies for supporting clients with co-occurring sexual assault and substance use include:
- sharing information between counsellor/advocates and clinicians;
- providing support for ongoing professional development;
- sharing new information and new evidence-based practices;
- supporting networking between the sexual assault and AOD treatment sectors, particularly those used for referrals and secondary consultations; and
- supporting staff by encouraging self-care.
Further reading and resources
Effects of sexual assault
- Working with adult survivors of child sexual assault <http://www.secasa.com.au/pages/working-with-adult-survivors-of-child-sexual-assault/>
- The impacts of sexual assault on women
- Dealing with sexual abuse: Men dealing with the effects of childhood sexual abuse and sexual assault
- The long-term effects of child sexual abuse
- The effects of childhood sexual abuse <http://www.secasa.com.au/pages/the-effects-of-childhood-sexual-abuse/>
- "Ripple" effects of sexual assault (the effects of sexual assault on families, professionals and society as a whole)
Disclosure of sexual assault
- Responding to young people disclosing sexual assault
- How to ask women about intimate partner violence
Effects of alcohol and other drug use
- Fact sheets and articles on the people, settings and specific drugs in AOD use <http://www.druginfo.adf.org.au/fact-sheets/fact-sheets>
- Intake process and tools
- For doctors: Keeping the Doctor Alive: A Self-Care Guidebook for Medical Practitioners
- For psychologists: Self-Care for Psychologists: Lifeline's Learnings
- Vicarious trauma: The Impact of Secondary Exposure to Trauma on Mental Health Professionals
- ReachOut.com self-care assessment
Mandatory reporting laws
- Australian Bureau of Statistics. (2011). Recorded crime - victims, Australia, 2010 (Cat. No 4510.0). Canberra: ABS. Retrieved from <www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4510.02010?OpenDocument>.
- Australian Bureau of Statistics. (2013). Personal Safety Survey, Australia, 2012 (Cat. No. 4906.0). Canberra: ABS. Retrieved from <www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4906.0Main+Features12012?OpenDocument>.
- Australian Institute of Health and Welfare. (2015). Alcohol use (NDSHS 2013 key findings). Canberra: AIHW. Retrieved from <www.aihw.gov.au/alcohol-and-other-drugs/ndshs/2013/alcohol/>.
- Breckenridge, J., Salter, M., & Shaw, E. (2012). Use and abuse: Understanding the intersections of childhood abuse, alcohol and drug use and mental health. Mental Health and Substance Use, 5(4), 314-327.
- Cutajar, M. C., Mullen, P. E., Ogloff, J. R., Thomas, S. D., Wells, D. L., & Spataro, J. (2010). Psychopathology in a large cohort of sexually abused children followed up to 43 years. Child Abuse and Neglect, 34(11), 813-822. doi:10.1016/j.chiabu.2010.04.004
- Darke, S. (2013). Commentary on Sartor et al. (2013): Trauma and drug use. More evidence for self-medication? Addiction, 108(5), 1001. doi:10.1111/add.12154
- Dinwiddie, S., Heath, A. C., Dunne, M. P., Bucholz, K. K., Madden, P. A., Slutske, W. S. et al. (2000). Early sexual abuse and lifetime psychopathology: A co-twin-control study. Psychological Medicine, 30(1), 41-52.
- Grayson, C. E., & Nolen-Hoeksema, S. (2005). Motives to drink as mediators between childhood sexual assault and alcohol problems in adult women. Journal of Traumatic Stress, 18(2), 137-145. doi:10.1002/jts.20021
- Matthews, S., Jayasekara, H., & Lloyd, B. (2012). Alcohol-related harms and use across Victorian LGAs 2000/01 to 2009/10 (Victorian Alcohol Statistics Series). Fitzroy, Vic.: Turning Point Alcohol and Drug Centre Retrieved from <tinyurl.com/zovnqhq>.
- Miranda, R., Meyerson, L. A., Long, P. J., Marx, B. P., & Simpson, S. M. (2002). Sexual assault and alcohol use: Exploring the self-medication hypothesis. Violence and Victims, 17(2), 205-217. doi:10.1891/vivi.188.8.131.52650
- Nelson, E. C., Heath, A. C., Madden, P. A., Cooper, M. L., Dinwiddie, S. H., Bucholz, K. K. et al. (2002). Association between self-reported childhood sexual abuse and adverse psychosocial outcomes: Results from a twin study. Archive of General Psychiatry, 59(2), 139-145.
- Padgett, D. K., Hawkins, R. L., Abrams, C., & Davis, A. (2006). In their own words: Trauma and substance abuse in the lives of formerly homeless women with serious mental illness. American Journal of Orthopsychiatry, 76(4), 461-467.
- Price-Robertson, R., Bromfield, L., Vassallo, S., & Scott, D. (2013). The prevalence of child abuse and neglect (CFCA Resource Sheet). Melbourne: Australian Institute of Family Studies. Retrieved from <www3.aifs.gov.au/cfca/publications/prevalence-child-abuse-and-neglect>.
- Quadara, A., Stathopoulos, M., & Jenkinson, R. (2015). Establishing the connection [between alcohol and other drug use and sexual victimisation]: State of knowledge paper. Sydney: ANROWS. Retrieved from <media.aomx.com/anrows.org.au/s3fs-public/Final%20Landscapes%2024%207%202015.pdf>.
- Victoria Police. (2014). Crime statistics 2013/14: Official release. Melbourne: Victoria Police. Retrieved from <www.police.vic.gov.au/retrievemedia.asp?Media_ID=72176>.
- Whitelaw, A. (2015, 21 March). Prescription drug deaths in Victoria eclipse road fatalities. The Age. Retrieved from <www.theage.com.au/victoria/prescription-drug-deaths-in-victoria-eclipse-road-fatalities-20150321-1m4mjq.html>.
These guidelines have been prepared by Mary Stathopoulos and Rebecca Jenkinson at the Australian Institute of Family Studies, with funding provided by the Australia's National Research Organisation for Women's Safety. We are indebted to our research partners, Trevor King from UnitingCare ReGen and Jane Vanderstoel from CASA Forum, for their support, consultation and feedback, and to Antonia Quadara and Daryl Higgins at the Australian Institute of Family Studies for their guidance and support. We extend a special thanks to the research participants for their contributions and generosity of time.
Australian Institute of Family Studies. (2016). Establishing the connection: Guidelines for practitioners and clinicians in the sexual assault and alcohol and other drug sectors. Melbourne: AIFS.