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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 1 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. 2 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 3 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 4 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 5 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 6 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 7 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 8 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 9 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 10 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 11 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 12 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 13 Phyllis Brashler Suicide Prevention & MH Coordinator, MDH (651) 201201-3586 [email protected] 14