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International Journal of Mental Health Nursing (2018) 27, 1587–1591 doi: 10.1111/inm.12495

E DITORIAL
Connecting past and present: Nurses’ role in
identifying signs of child sexual abuse in adults
and supporting survivors
Child sexual abuse (CSA) is a particular form of adulthood. Exposure to often repeated trauma at an
trauma, known as complex trauma. Unlike ‘single inci- early age activates an ongoing physiological ‘fight and
dent’ trauma, the complex trauma of CSA is cumula- flight’ response that fails to subside when the trauma
tive, underlying, and interpersonally generated cannot be ‘escaped’ or resolved adequately (Kezelman
(Courtois & Ford 2009). It can have significant and 2016), or leads to ongoing or triggered activation of
long-lasting health impacts and is a key predictor of withdrawal-type responses of ‘tonic immobility’ or ‘col-
psychological distress in later life (Flett et al. 2012). lapsed immobility’ (Kozlowska et al. 2015, p. 264) and
Rates of sexual abuse among adolescents and chil- dissociation. This leads to patterns of fear-based learn-
dren vary, with one study finding 26.6% of girls and ing and creates capacity for altered cognitions and cop-
5.1% of boys in the United States had experienced sex- ing mechanisms into adulthood (Marshall & Leifker
ual abuse or assault as a minor (Finkelhor et al. 2014). 2014). Childhood coping mechanisms and strategies,
Survivors are often associated with higher levels of dys- initially adaptive and protective in the context of the
functional family environments, neglect, and rejection trauma, become risk factors for adult ill health and can
(Gold 2000). Although trauma will be experienced dif- negatively impact mental health over time (Felitti et al.
ferently by different people (Williams & Sommer 1998).
2002), survivors often access diverse health profession- Post-traumatic stress disorder (PTSD) is one such
als and support services to respond to and deal with consequence of CSA (Dorsey et al. 2017; Elklit et al.
the ramifications of childhood sexual abuse. As people 2014; Flett et al. 2012), although disputed by some
who have experienced CSA are at high risk of researchers (Mercado et al. 2015). The emotional and
retraumatization, a trauma-informed approach to both physical health effects of ‘complex’ trauma that occur
individual and systemic support and treatment is with CSA are far more extensive than those with PTSD
needed (Kezelman & Stavropoulos 2012). Often, it can (Courtois & Ford 2009). Early life trauma is particu-
take many years for survivors to seek help due to chal- larly damaging because it affects the development of
lenges around disclosure and trust, with disclosure the self and a range of functions including the ability
occurring to informal support sources (Starzynski et al. to regulate emotion (Courtois & Ford 2009; Schore
2017). Fifty-eight per cent of Canadians who had expe- 2003; Starzynski et al. 2017).
rienced ‘historical’ child sexual abuse did not disclose Other outcomes can include anxiety and depression,
the abuse for 5 years or more and one-fifth did not dis- substance abuse (Flett et al. 2012), eating disorders
close at all (Hebert et al. 2009). This suggests that and weight gain (Koetting 2016; Oral et al. 2016), and
many take the trauma of their abuse to the grave, suicidality (Knight 2015). One study found overeating
although disclosure of childhood sexual abuse has been was used by survivors of CSA to make themselves ‘in-
reported in the palliative care setting, weeks to months visible’ to abusers and to minimize the possibility of
before death (Wygant et al. 2011). further abuse (Koetting 2016). Another found that CSA
The impacts of CSA can be psychological, emo- could lead to not only negative cognitions, such as low
tional, social, and physical and can extend through to self-esteem and self-blame, but also higher levels of
risky sexual behaviour (Marshall & Leifker 2014). This
would act as a catch 22, whereby sexual risk-taking
Funding Statement: Improving Mental and Critical Care Health
(MaCCH) – UTAS funding awarded under the UTAS Research behaviour served to reinforce their negative cognitions
Themes: Better Health Research Development Grant Scheme, and lead to an accumulation of negative experiences.
supported by the Office of the Deputy Vice Chancellor and FoH
(C0025653).
Survivors of CSA will often access a range of health
Conflict of Interest statement: Authors declare that there is no professionals as adults, often in relation to issues
conflict of interest.

© 2018 Australian College of Mental Health Nurses Inc.


1588 EDITORIAL

associated with their experiences of CSA, such as defective, due to their lifestyle choices or addictions,
addiction, eating disorders, suicidal ideation, or mental social workers were found to intervene paternalistically,
illness. Yet, the focus can often be on these present- creating a negative interaction and damaging therapeu-
day disorders or difficulties, without additionally identi- tic outcomes (Levenson 2017). This is compounded as
fying the issues underlying them (Knight 2015). Under- CSA survivors report high levels of dissatisfaction with
standing the impact of past childhood trauma, such as current social support, which can contribute to the risk
CSA, on current behaviours, symptoms, and risk fac- of PTSD (Stevens et al. 2013). Without appropriate
tors, including the coping strategies people adopt, is an social support and adequate professional intervention
important aspect of modern healthcare. A failure to and support, the consequences of CSA on survivors are
understand and resolve the impacts of the past leads to compounded.
a failure to adequately support, refer, and treat the cur- The most significant current research relates to
rent challenges. Given the prevalence of the CSA and trauma-informed care (TIC) (Cleary & Hungerford
its costs, health professionals and in particular mental 2015). TIC is a strengths-based framework (Kezelman
health professionals are uniquely positioned, to identify 2016) that assists the survivor to develop mechanisms
and help address its associated challenges (Kenny & for coping with distress and effective daily functioning
Abreu 2015). (Gold 2001). TIC is not simply focussed on treating
Research suggests that while health professionals trauma, but ideally underpins all interactions, clinical
may be knowledgeable about CSA, they are often not and supportive, including all nursing interactions. It
entirely confident or well supported when working with focuses on ‘what happened to a person’, that is the
these clients (Day et al. 2003). They may adopt the relationship between past events and current circum-
‘don’t ask, don’t tell’ approach or be concerned about stances, and prioritizes safety, empowerment, trustwor-
re-traumatising patients if childhood sexual abuse is thiness, choice, and collaboration (Fallot & Harris
suspected (Wygant et al. 2011, p. 292). Health profes- 2009). To be effective, a trauma-informed service pro-
sionals need to use a trauma-informed lens (Kezelman vider responds empathetically to the person (Glover
& Stavropoulos 2012) to identify that people presenting et al. 2010), and their trauma, and does not force sur-
with health and psychosocial challenges may have vivors to express feelings or recount details. Integral to
underlying impacts from childhood experiences or ways TIC is the survivor’s ability to succeed in coping and
of coping as a result of unresolved trauma. This maxi- growing (Koetting 2016). Bateman et al. (2013) in their
mizes the potential for their therapeutic engagement Australian national strategic direction position paper
with survivors of CSA (Knight 2015). Furthermore, for mental health service policy seek to embed the
current research states that mental health professionals principles of TIC across all health and human services,
are not routinely enquiring about CSA in acute mental including professionals and diverse personnel.
health settings and that service providers may need to There is also a range of trauma-focused interven-
incorporate mandatory enquiry about CSA into mental tions that are used or could be used to deliver timely
health assessments (Hepworth & McGowan 2013). evidence-based treatment to child and adolescent sur-
There are, however, risks associated with a mandatory vivors of CSA to resolve or manage the fallout of such
enquiry approach, where direct enquiry can be experi- trauma (Dorsey et al. 2017). Cognitive behavioural
enced more as an interrogation and the survivor can be therapies have been found to be effective first-line
triggered into a traumatic state (Moloney et al. 2018). treatment responses, both with and without parental
Yet, therapeutic potential is not automatically maxi- involvement, and have been the subject of extensive
mized in the healthcare sector, when training and research (Dorsey et al. 2017). Similar research has sup-
experience around sexual assault or abuse (SA) are ported the use of cognitive behavioural therapy (CBT),
lacking and opportunities to build trust are missed. while finding that parental and family involvement
One Australian study found mental health workers lack through parental–child interaction and psychotherapy
adequate SA training and rarely referred these sur- therapies were recommended (Oral et al. 2016).
vivors to health professionals specializing in SA recov- Research has also supported longer term contemporary
ery (McLindon & Harms 2011). Another article psychodynamic psychotherapy in resolving personality
identified the often-oppressive nature of social services sequelae of childhood complex trauma, including CSA
and the way in which this caused marginalized clients (Stevenson & Meares 1992). Applying principles from
to mistrust them (Levenson 2017). When practitioners this psychodynamic approach that pays particular atten-
were not trauma-informed and clients were viewed as tion to the survivor’s state of mind and to the language

© 2018 Australian College of Mental Health Nurses Inc.


EDITORIAL 1589

of the therapeutic conversation has been found to be multidisciplinary team or service can take considerable
useful in brief and acute approaches to mental health time and training (Moloney et al. 2018), but represents
sequelae of CSA (Haliburn & Baker 2014; Moloney an investment in better practice. However, some skill
et al. 2018; Skinner & McLean 2017). development can happen in shorter training, such as
While TIC is a universal approach for every inter- workshops, and is now guided by manualization of the
personal service interaction, CBT, psychodynamic acute and ultra-brief approach (Barkham et al. 2017).
approaches, and other psychological interventions for Furthermore, the use of nurse educators, Clinical
treating CSA and its impact may not be delivered at Nurse Specialists, and Clinical Nurse Consultants, who
the first contact between survivor and health profes- can model best practice in real-world settings, is a time
sional. Indeed, often the first point of contact comes effective way to build skills and shift culture. Nursing,
many years after trauma and may occur in the emer- as a profession, needs to provide nursing care as well
gency department, in an interaction with a child health as to optimize that care by implementing trauma-
nurse, or a diversity of other healthcare interactions. informed approaches and acts as the ever-important
Nurses are often the first point of contact with conduit between other health and social services.
patients. Trauma-informed nurses can be supportive When CSA survivors are often presenting as adults
while being in a unique position to assess cues and col- with signs of possible trauma, then nurses need to
lect relevant information. So the question then know how to identify this, and thoughtfully, carefully
becomes whether nurses as a profession are trauma- connect past and present, and support survivors on
informed and equipped with the knowledge, skills, atti- their road to recovery. Listening and validating patient
tudes, and confidence to recognize that the current cir- experiences combined with a flexible and responsive
cumstances of a patient can or may reflect past trauma. interpersonal approach, nursing professionalism/exper-
Are nurses able to identify the possible impacts of the tise, provide an environment in which a recovery jour-
past and the ways people cope with prior trauma to ney can begin or be advanced.
better understand their role in supporting patients,
minimizing the risk of retraumatization, and optimizing Michelle Cleary,1 Sancia West,1 Loyola
2,3,4 5
their treatment in the present? Can they recognize the McLean, Cathy Kezelman, Sara Karacsony 1
traumatic states of mind and dissociative states that can and Rachel Kornhaber 1
1
present in complex ways in the clinic, in the emergency School of Health Sciences, College of Health and
department, and on a mental health home visit? Medicine, University of Tasmania, Sydney, 2Faculty of
This is important because the often hidden CSA is a Medicine and Health, Brain and Mind Centre, The
major contributor to underlying mental health prob- University of Sydney, Camperdown, 3Westmead Psy-
lems. And if this link between past and present is chotherapy Program, Cumberland Hospital, Western
understood, are nurses ready and able to appropriately Sydney Local Health District and The University of
engage survivors in the moment and then refer them Sydney Westmead Clinical School,
4
on to services that are best able to help them further? Consultation-Liaison Psychiatry, Royal North Shore
With demands on nurses’ time, a key concern for deliv- Hospital and 5Blue Knot Foundation, Sydney, New
ering clinical best practice (Abrahamson et al. 2012), South Wales, Australia
nurses may not always be able to pursue the possible
clues of CSA and underlying trauma and to adequately REFERENCES
refer them for support. However, all nurses can
Abrahamson, K. A., Fox, R. L. & Doebbeling, B. N. (2012).
become trained in trauma-informed principles and in Original Research: Facilitators and barriers to clinical
their role in helping patients to feel safe, heard, under- practice guideline use among nurses. The American
stood, and supported. Journal of Nursing, 112, 26–35.
There is a body of work supporting acute and ultra- Barkham, M., Guthrie, E., Hardy, G. E. & Margison, F.
brief interventions suitable to emergency department (2017). Psychodynamic-Interpersonal Therapy: A
settings, prioritizing the empathically attuned and per- Conversational Model. London, UK: Sage.
Bateman, J., Henderson, C. & Kezelman, C. (2013). Trauma-
son-centred approach to engagement, interviewing, and
informed care and practice: towards a cultural shift in
assessment used in the cognate area of deliberate self- policy reform across mental health and human services in
harm, a common presentation in those with complex Australia. A National Strategic Direction, Position Paper
trauma (Guthrie et al. 2001, 2003). Developing these and Recommendations of the National Trauma-informed
skills for nurses and the other members of a Care and Practice Advisory Working Group. Sydney,

© 2018 Australian College of Mental Health Nurses Inc.


1590 EDITORIAL

Australia. [Cited 24 April 2018]. Available from: http:// interpersonal therapy for deliberate self-poisoning. The
www.mhcc.org.au/media/32045/ticp_awg_position_paper__ Australian and New Zealand Journal of Psychiatry, 37, 532–
v_44_final___07_11_13.pdf 536.
Cleary, M. & Hungerford, C. (2015). Trauma-informed care and Haliburn, J. & Baker, A. (2014). What has happened to the
the research literature: How can the mental health nurse take practice of short term dynamic psychotherapy in Australia’s
the lead to support women who have survived sexual assault? mental health services? A multidisciplinary training
Issues in Mental Health Nursing, 36, 370–378. programme in Western Sydney. Australasian Psychiatry, 22,
Courtois, C. A. & Ford, J. D. (2009). Treating Complex 443–446.
Traumatic Stress Disorders: An Evidence-Based Guide. Hebert, M., Tourigny, M., Cyr, M., McDuff, P. & Joly, J.
New York, NY: Guilford Press. (2009). Prevalence of childhood sexual abuse and timing
Day, A., Thurlow, K. & Woolliscroft, J. (2003). Working with of disclosure in a representative sample of adults from
childhood sexual abuse: A survey of mental health Quebec. Canadian Journal of Psychiatry, 54, 631–636.
professionals. Child Abuse & Neglect, 27, 191–198. Hepworth, I. & McGowan, L. (2013). Do mental health
Dorsey, S., McLaughlin, K. A., Kerns, S. E. U. et al. (2017). professionals enquire about childhood sexual abuse during
Evidence base update for psychosocial treatments for routine mental health assessment in acute mental health
children and adolescents exposed to traumatic events. Journal settings? A substantive literature review. Journal of
of Clinical Child and Adolescent Psychology, 46, 303–330. Psychiatric and Mental Health Nursing, 20, 473–483.
Elklit, A., Christiansen, D. M., Palic, S., Karsberg, S. & Kenny, M. C. & Abreu, R. L. (2015). Training mental health
Eriksen, S. B. (2014). Impact of traumatic events on professionals in child sexual abuse: Curricular guidelines.
posttraumatic stress disorder among Danish survivors of Journal of Child Sexual Abuse, 24, 572–591.
sexual abuse in childhood. Journal of Child Sexual Abuse, Kezelman, C. (2016). Trauma-informed care and practice in
23, 918–934. nursing. Australian Nursing & Midwifery Journal, 24, 28.
Fallot, R. D. & Harris, M. (2009). Creating cultures of Kezelman, C. & Stavropoulos, S. (2012). ‘The Last Frontier’:
trauma-informed care (CCTIC): A self-assessment and Practice guidelines for treatment of complex trauma and
planning protocol. Iowa. [Cited 24 April 2018]. Available trauma informed care and service delivery. Kirribilli,
from: https://www.healthcare.uiowa.edu/icmh/documents/ Sydney. [Cited 7 May 2018]. Available from: http://m.rec
CCTICSelf-AssessmentandPlanningProtocol0709.pdf overyonpurpose.com/upload/ASCA_Practice%20Guidelines
Felitti, V. J., Anda, R. F., Nordenberg, D. et al. (1998). %20for%20the%20Treatment%20of%20Complex%20Tra
Relationship of childhood abuse and household uma.pdf
dysfunction to many of the leading causes of death in Knight, C. (2015). Trauma-informed social work practice:
adults. The Adverse Childhood Experiences (ACE) Study. Practice considerations and challenges. Clinical Social
American Journal of Preventive Medicine, 14, 245–258. Work Journal, 43, 25–37.
Finkelhor, D., Shattuck, A., Turner, H. A. & Hamby, S. L. Koetting, C. (2016). Trauma-informed care: Helping patients
(2014). The lifetime prevalence of child sexual abuse and with a painful past. Journal of Christian Nursing, 33, 206–
sexual assault assessed in late adolescence. The Journal of 213.
Adolescent Health, 55, 329–333. Kozlowska, K., Walker, P., McLean, L. & Carrive, P. (2015).
Flett, R. A., Kazantzis, N., Long, N. R. et al. (2012). The Fear and the defense cascade: Clinical implications and
impact of childhood sexual abuse on psychological distress management. Harvard Review of Psychiatry, 23, 263–287.
among women in New Zealand. Journal of Child & Levenson, J. (2017). Trauma-informed social work practice.
Adolescent Psychiatric Nursing, 25, 25–32. Social Work, 62, 105–113.
Glover, D. A., Loeb, T. B., Carmona, J. V. et al. (2010). Marshall, A. D. & Leifker, F. R. (2014). The impact of
Childhood sexual abuse severity and disclosure predict childhood physical abuse and age of sexual initiation on
posttraumatic stress symptoms and biomarkers in ethnic women’s maladaptive posttraumatic cognitions. Journal of
minority women. Journal of Trauma & Dissociation, 11, Aggression, Maltreatment & Trauma, 23, 136–150.
152–173. McLindon, E. & Harms, L. (2011). Listening to mental
Gold, S. (2000). Not Trauma Alone: Therapy for Child Abuse health workers’ experiences: Factors influencing their
Survivors in Family and Social Context. New York, NY: work with women who disclose sexual assault.
Brunner-Routledge. International Journal of Mental Health Nursing, 20, 2–11.
Gold, S. (2001). Conceptualizing child sexual abuse in Mercado, R. C., Wiltsey-Stirman, S. & Iverson, K. M. (2015).
interpersonal context: Recovery of people, not memories. Impact of childhood abuse on physical and mental health
Journal of Child Sexual Abuse, 10, 51–71. status and health care utilization among female veterans.
Guthrie, E., Kapur, N., Mackway-Jones, K. et al. (2001). Military Medicine, 180, 1065–1074.
Randomised controlled trial of brief psychological Moloney, B., Cameron, I., Baker, A. et al. (2018).
intervention after deliberate self poisoning. British Implementing a trauma-informed model of care in a
Medical Journal, 323, 135–138. community acute mental health team. Issues in Mental
Guthrie, E., Kapur, N., Mackway-Jones, K. et al. (2003). Health Nursing, 1–7. https://doi.org/10.1080/01612840.
Predictors of outcome following brief psychodynamic- 2018.1437855.

© 2018 Australian College of Mental Health Nurses Inc.


EDITORIAL 1591

Oral, R., Ramirez, M., Coohey, C. et al. (2016). Adverse interpersonal violence mediate the link between childhood
childhood experiences and trauma informed care: The abuse and posttraumatic stress symptoms. Behavior
future of health care. Pediatric Research, 79, 227–233. Therapy, 44, 152–161.
Schore, A. N. (2003). Affect Dysregulation and Disorders of Stevenson, J. & Meares, R. (1992). An outcome study of
the Self. New York, NY: WW Norton & Company. psychotherapy for patients with borderline personality
Skinner, L. & McLean, L. (2017). The conversational model disorder. The American Journal of Psychiatry, 149, 358–
and child and family counselling: Treating chronic 362.
complex trauma in a systemic framework. Australian and Williams, M. B. & Sommer, J. (2002). Trauma in the new
New Zealand Journal of Family Therapy, 38, 211–220. millennium. In: M. Williams & J. Sommers (Eds). Simple
Starzynski, L. L., Ullman, S. E. & Vasquez, A. L. (2017). and Complex PTSD: Strategies for Comprehensive
Sexual assault survivors’ experiences with mental health Treatment in Clinical Practice (pp. xix–xxii). New York,
professionals: A qualitative study. Women & Therapy, 40, NY: Haworth.
228–246. Wygant, C., Hui, D. & Bruera, E. (2011). Childhood sexual
Stevens, N. R., Gerhart, J., Goldsmith, R. E., Heath, N. M., abuse in advanced cancer patients in the palliative care
Chesney, S. A. & Hobfoll, S. E. (2013). Emotion setting. Journal of Pain and Symptom Management, 42,
regulation difficulties, low social support, and 290–295.

© 2018 Australian College of Mental Health Nurses Inc.

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