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Promoting Health and
Healing
Addressing the Mental Health Impacts
of Sexual Assault from an Advocacy
Perspective
Phyllis Brashler
Minnesota Department of Health
Setting the Stage
Standpoint
Framework
Public health approach
Everything starts with advocacy & movement
Acknowledge history
Acknowledge differences and strengths
Challenge assumptions and push for better
approaches
Ultimate goal: helping survivors
Overview
Key concepts and definitions
BroadBroad-based information about the mental
health affects of sexual violence and trauma
Strategies for supporting survivors with mental
health needs and preventing suicide/selfsuicide/self-injury
Resources for additional help
Implications for prevention
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Definitions: Mental Health
Mental health is a state of wellwell-being in which the individual realizes
his or her own abilities, can cope with the normal stresses of life,
life,
can work productively and fruitfully, and is able to make a
contribution to his or her community.
--World
--World Health Organization
Our goal is to foster environments where everyone has an opportunity
opportunity
to live, learn, work, and fully participate in communities where
they experience joy, health, love and hope.
The Mental Health Continuum
Emotional Wellness
Mental Illness
Mental Illness
A broad range of mental and emotional conditions characterized by
alterations in thinking, mood, and/or behavior.
Mediated by the brain
Associated with distress and/or disruptions in functioning
The term “mental illness” is more generally used to refer to
psychiatric or mental health conditions that are more chronic
and cause greater disruption in functioning.
The term “mental health conditions” or “psychiatric conditions” is
often used to refer more generally to symptoms or diagnoses
that are less likely to cause long-lasting disability.
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Brain P.E.T. Scan
Healthy
Depressed
Transaxial
Sagittal
Red indicates greater brain activity – blue indicates lesser
Mental Illness
The Illness Model
Limitations of the medical model
DoubleDouble-edged sword of stigma
Current Thinking on MI
Complex interactions between an individual’
individual’s
physical health, biological makemake-up, and social
environment
Trauma theory
Trauma:
when an individual’
individual’s ability to integrate his/her
emotional experience is overwhelmed, or the individual
experiences a threat to life, bodily integrity, or sanity.
Data
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Data: Why Bother?
Limitations
Numbers vs. Experience
Complex realities
Good data vs. Bad data
Methodological limitations
Benefits
Some things really are true!
Document need
Target resources
Understand problems
Sexual Violence and Mental Health
MultiMulti-dimensional:
Individuals who live with serious mental illness are at
higher risk for experiencing sexual violence, as well as
other forms of victimization.
Sexual violence may contribute to the development of a
mental health condition or mental illness.
Wide range of abuse experiences varying impact on
mental health
Severity, frequency, relationship to perpetrator, age, existing
risk & protective factors
Mental Health Impacts of Abuse
Diagnoses are Organized Observations
Depression
Posttraumatic Stress Disorder/Complex Trauma
Dissociation
Suicidal Ideation & Behavior
Suicide attempts & selfself-injury
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Depression: Symptoms
Depressed mood most of the day, nearly every day (in children
and adolescents can be irritable mood)
Markedly diminished interest or pleasure in all or almost all
activities most of the day
Significant weight loss or weight gain
Insomnia or hypersomnia nearly every day
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate
Recurrent thoughts of death (not just fear of dying), suicidal
ideation without a plan, or a suicide attempt or specific plan for
for
committing suicide
Depression & SV
Koss (2003) Literature Review
Lifetime prevalence of Major Depressive Disorder
2-3x higher for women who have experienced SA
than women who have not.
Age & Multiple Victimizations Important
Women
who were abused than once and whose first
victimization occurred during childhood were twice as
likely to experience depression than women whose first
victimization occurred during adulthood.
Depression + PTSD may be unique
PTSD & Complex Trauma
Exposure to a traumatic event in which the person
experienced, witnessed, or was confronted by death or
serious injury to self or others
ReRe-experiencing: memories, flashbacks, other triggers
Avoidance of triggers; numbness; shutting down emotionally
Increased physiological arousal & hypervigilance
Increases a woman’
woman’s chance of developing firstfirst-onset
major depression & alcohol abuse affects ability to
seek help, make decisions, and access resources.
Emerging Constructs: Complex Trauma
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PTSD
Prevalence of PTSD
Lifetime prevalence
estimates for survivors of
CSA or ASA range from 2424-65%
Adult victims of sexual assault, particularly
completed rape, represent the largest single
group of trauma victims affected by PTSD.
Women who experience SA in the context of
physical and/or psychological abuse experience a
greater number of PTSD symptoms.
PTSD: Course & Recovery
SingleSingle-event:
Distress peaks at 3 weeks postpost-assault for adult
victims of single assault & continue at this level
for the next month
Symptoms may resolve after 3 months; some can
persist for 18 months or longer; nearly 25% of
survivors continue to be affected for several years.
Average remission time ranges from 2525-29
months.
Dissociative Identity Disorder
Dissociation is a mental process, which produces a lack of
connection in a person’s thoughts – separating out an
individual’s emotions, physical feelings, responses,
actions, or sense of identity.
While the person is dissociating, some information –
particularly the circumstances associated with traumatic
events -- is not associated with other information as it
normally would be. It is held in some peripheral
awareness.
--Olga Trujillo
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Suicide & SelfSelf-Injury
Suicide Ideation
Serious thoughts about suicide
Suicide Attempts
History of sexual assault closely linked to suicide
attempts
History
of sexual trauma before 16 is a particularly strong
correlate of attempted suicide.
PTSD in combination with any form of child
maltreatment increases risk of suicide attempt.
Suicide in Minnesota
In 2007, 571 people died by suicide.
Minnesota’
Minnesota’s suicide rate has risen from 8.9 per
100,000 in 2000 to 11.0 per 100,000 in 2007.
The number of people who died by suicide was
nearly 5 times higher than the number of
homicide victims.
Leading methods: Guns, suffocation, and
poisoning.
Gender and Suicide
Men are much more likely to complete suicide.
2007: 571 suicides (462 men, 109 women)
Rates
are increasing overall, but particularly among
women age 3535-54 and men age 5555-64.
More lethal methods (Firearms, Suffocation)
Gender role norms as protective?
Women are much more likely to attempt suicide.
Hospital discharge data: 5721 patients discharged for
nonnon-fatal selfself-injury in 2007
2,032 Male
(35.5%), 3,689 Female (64.5%)
mechanisms: 61.7% Poisoning, 28.5%
Cutting/Piercing
Leading
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Minnesota Student Survey (2007)
Of 9th grade students:
34.6% of those who reported attempting suicide also
reported experiencing unwanted or forced sexual touching.
14.2% of those who thought about suicide, but not attempted
4.7% of students who had never thought about or attempted
suicide
30.2% of those who reported attempting suicide also
reported being forced to have sex or do something sexual
against their will by a dating partner.
10.7% of those who thought about suicide, but not attempted
4% of students who had never thought about or attempted
suicide
ACE Study
7 Categories of Adverse Childhood Experiences
Impacts
The total sample had a mean mental health score of 76.6
12% of women and 6.5% of men reporting CSA had a MH score of <52.
<52.
19% of women and 12% of men reporting CSA & physical abuse had a
MH score of <52.
Survivors of CSA:
50% of the sample experienced at least 1; 25% experienced 2 or more
more
21% reported experiencing CSA (25%/women, 16%/men)
More than twice as likely to report suicide attempts
40% increased risk of marrying an alcoholic
4040-50 more likely to report marital difficulties
Dose response b/w number of ACEs and Health Outcomes
SA in the context of DV
Multiple forms of victimization increase the
likelihood that a survivor will experience mental
health conditions or mental illness and affects
the severity of that condition, especially if the
perpetrator is a family member or intimate
partner.
More abuse = more risk
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Common Experiences
Difficulties with feelings
SelfSelf-soothing
Hypervigilance
Impulsiveness & anger
Sleep disturbances
Feeling disengaged
Low stamina
Difficulties with thinking
and processing
Screening out stimuli
Processing information
Disturbing thoughts
Sense of restricted
options
Low tolerance for stress
Difficulties in Interaction:
Strong response to negative feedback
Sense of urgency
Personal AND Political
Keep in mind:
How it feels to experience trauma, or to
experience a mental illness.
Imagine feeling trapped in a state of mind that
feels like it is out of your control.
Our goal: to work together towards healing and
recovery from trauma.
Strategies
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Suicide Risk & Protective Factors
Key Risk Factors
Mental Illness
Substance Abuse
Trauma
Poor Coping Skills
Impulsiveness
Previous Attempts
Unemployment
Social Isolation
Protective Factors
Social Support
Belonging & caring
Effective Coping Skills
Problem Solving Skills
Policies & Culture that:
Approve/encourage help
seeking behavior
Protect those who seek
help
Warning Signs of Suicide
IS PATH WARM?
Ideation
Substance Use
Purposelessness
Anxiety
Trapped
Hopelessness
Withdrawal
Anger
Recklessness
Mood Change
How they might feel:
Can’
Can’t stop the pain
Can’
Can’t think clearly
Can’
Can’t make decisions
Can’
Can’t see any way out
Can’
Can’t sleep, eat or work
Can’
Can’t get out of depression
Can’
Can’t make sadness go away
Can’
Can’t see a future w/out pain
Can’
Can’t see themselves as
worthwhile
Can’
Can’t get someone’
someone’s attention
Can’
Can’t seem to get control
What You Can Do
It is okay to talk about suicide.
"Do you ever feel so badly that you think about suicide?"
"Do you have a plan to commit suicide or take your life?"
"Have you thought about when you would do it (today, tomorrow,
next week)?"
"Have you thought about what method you would use?”
use?”
Listen without judgment
Stay with them & help them find help
Follow up on referrals
Help develop positive coping strategies, build skills
Ask about access to lethal means
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Assessing SelfSelf-Injurious Behavior
from Suicidal Behavior(s)
Behavior(s)
SelfSelf-Injurious Behavior
Wants relief of pain
Little or no physical damage
Will hide injury
Shares this with the world
Chronic, repeated
Several methods
Broad thinking
Has some hope
May or may not have other
symptoms
Suicidal Behavior
Wants pain to end
Lethal physical damage
Rarely shares everything
Infrequent, acute
Single method (or increases)
Tunnel vision
No hope
Has other symptoms
(Adapted from Walsh, 2005)
TraumaTrauma-Sensitive Programs
Learning new ways to talk about mental health
Evaluate what you do from the perspective of someone
who has experienced trauma.
Common responses to trauma and abuse
Normalize it
Interaction and Engagement, Hotlines/Support Groups
Physical Environment
Space and Routines
Ask survivors about situations or conditions that make
them feel less safe and offer alternatives when it would
be helpful.
Safety, confidentiality, and choice are key.
Services
Assess existing programs/services
CoCo-location of services
Partnerships for clinical supervision of
advocates (Maine)
Staff training
Relationship development
Cross training with MH professionals
Job shadowing between sectors
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Resources
Suicide Prevention Resources
National Lifeline: (800) 273273-8255
Suicide Prevention Resource Center
http://www.sprc.org
http://www.sprc.org
MDH Website
http://www.health.state.mn.us/suicideprevention
http://www.health.state.mn.us/suicideprevention
SAVE
http://www.save.org
http://www.save.org
JED Foundation (College(College-age)
http://www.jedfoundation.org
/
http://www.jedfoundation.org/
American Association of Suicidology
http://www.suicidology.org
Mental Health: Peer Support
Support for individuals with mental health
conditions or illnesses that is provided by other
consumers of mental health services.
“Peer support is a system of giving and receiving help founded on
key principles of respect, shared responsibility, and mutual
agreement of what is helpful. Peer support is not based on
psychiatric models and diagnostic criteria. It is about
understanding another’s situation empathically through the shared
experience of emotional and psychological pain.”
-Shery Mead, www.mentalhealthpeers.com
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Mental Health: Peer Support
Wellness Recovery Action Plans
A strategy that helps people who experience mental
illness to monitor their symptoms, to play to stay
well, and to have a specific strategy to use to restore
a state of wellness. – Mary Ellen Copeland,
www.mentalhealthrecovery.com
Mental Health Consumer Survivor Network
DHS Peer Support Program
www.mhcsn.org
Mental Health Services
Mobile crisis teams
Children
Adults
CommunityCommunity-based, publicly funded services
available through counties.
Other DHS programs
SchoolSchool-linked MH services
Collaboratives
State Advisory Council/MH
Implications for Prevention
Prevention of the development of serious
mental illness/Reduction in symptoms
Prevention of suicide, selfself-injury
Prevention of CSA, ASA, revicitmization
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Phyllis Brashler
Suicide Prevention & MH Coordinator, MDH
(651) 201201-3586
[email protected]
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