1. Ontario Woman Abuse Screening Project
May 2010
Making Connections between Addictions, Mental Health and Woman Abuse/Sexual Violence/Trauma
Linda Murray, RN, BScN
Sexual Assault Nurse Examiner
Abused Women’s Service, Sexual Assault/Domestic Violence Treatment Centre, Chatham-Kent Health Alliance
Tonya Verburg
Residential Manager
Chatham Kent Women’s Centre

2. Woman Abuse

3. Woman abuse is any threat, act or physical force that is used to create fear, control or intimidate you.

4. Woman Abuse: Incidence and Prevalence
25% of all women have experienced physical or sexual violence at the hands of a marital or a common law partner
45% of incidents resulted in injury
In 85% of family violence cases reported to police, the victims were female
Women are 7 times more likely to be killed or hurt in their homes by someone known to them than by a stranger
60 % of women do not report abuse to police
DATA: Justice Statistics, Statistics Canada, 2006

5. Violence against women is not about losing control
Violence against women is not about losing control. It is the intentional control of another person.
The abuser is purposefully using verbal, non verbal or physical means to gain control over the other person. In most cases the abuser is not abusive or violent to others outside the family or home.

6. Power and Control
With all abuse, the abuser uses power over those they are abusing. Abusers often use alcohol or drugs as an excuse. But the abuser is responsible for his or her behaviour
Data: Spousal Abuse Fact Sheet, Family Violence, Department of Justice

7. Abusers are able to control their behavior—they do it all the time.
Abusers pick and choose whom to abuse. They don’t insult, threaten, or assault everyone in their life who gives them grief. Usually, they save their abuse for the people closest to them, the ones they claim to love.
Abusers carefully choose when and where to abuse. They control themselves until no one else is around to see their abusive behavior. They may act like everything is fine in public, but lash out instantly as soon as you’re alone.
Abusers are able to stop their abusive behavior when it benefits them. Most abusers are not out of control. In fact, they’re able to immediately stop their abusive behavior when it’s to their advantage to do so (for example, when the police show up or their boss calls).
Violent abusers usually direct their blows where they won’t show. Rather than acting out in a mindless rage, many physically violent abusers carefully aim their kicks and punches where the bruises and marks won’t show.

8. Originally developed by The Domestic Abuse Intervention Project, Duluth, USA Further adapted by London Abused Women’s Centre

9. Power and Control Exercise
Create a power and control wheel for women you work with, either with Mental Health Issues or Substance Abuse Issues
How are the tactics of abuse related to women’s use of drugs or their mental health

10. POWER AND CONTROL Using Intimidation, Threats and Coercion
Using Emotional Abuse
Putting her down, making her feel bad about self, feel guilty about past or present drug use, or MH condition
Threatening to hurt her if uses/does not use, hurt if goes to doctor, etc
Using Economic Abuse
Physical Abuse
Forcing into prostitution, forcing to sell drugs, prescribed or illegal, calling boss with concerns of MH,
Physically abusing her for her condition, for getting high, for not getting high
POWER AND
CONTROL
Using Isolation
Encouraging Dependence
Keeping her away from supportive people, preventing her from attending treatment
Introduce to drugs, buying drugs for her, make her think she needs meds for MH, post partum etc.
Making light of condition, saying she caused abuse by drug use or Mental illness
Treat her like a sex object, withhold sex or force even if traumatic, forcing into prostitution
Minimizing, Denying, Blaming
Sexual Abuse

11. Video
It’s not like I hit her

12. NOTE: Cycle of Violence is not the reality for all women
ONE week they could have come in crisis, following explosion while the next appointment they could be at honeymoon phase – so will present so differently.
Violence against women is a socialized problem, can go from generation to generation as they learn power and control – NEED STAT
- women stay as they want their partner to change, believe it can get better
- also have talked to women who stay because they know what will happen, if they are apart they do not know where he is in the cycle…
NOTE: Cycle of Violence is not the reality for all women

13. Women Who Face Additional Challenges
Rural Women
Geographic location
Isolation
Lack of transportation and other services
First Nations Women
High incidence &normalization of violence in First Nations community
absence of public education about women’s legal rights
often a First Nations woman has to leave her community to be free of the abuse
Rural: geographic location, isolation: lack of public transportation, other diverse services, economic conditions, access to services, lack of anonymity – close knit nature of the community as well as its small size
Denial in rural communities may also stem from the community’s image of itself as a haven, free from the ills associated with urban life
First Nations Women: high tolerance to violence in native community and an absence of public education about women’s legal rights – may be lack of trust of police and services unless they are native – often a native woman has to leave her community to be free of the abuse

14. Immigrant Women Women with Disabilities:
fear of jeopardizing their immigration status,
often economically dependent and financially insecure
language barrier
fear deportation and losing children
Women with Disabilities:
difficult to leave if abuser is caregiver,
barriers to access services, neglect is very prevalent in abusive relationship
viewed and treated as children,
considered to be non sexual
caregivers often seen as good people for taking on such a challenge
Immigrant Women: isolation due to their immigration context, fear of jeopardizing their immigration status, culturally prescribed role obligations and social pressure to remain in the marriage - often economically dependent and financially insecure – language barrier – lack occupational skills for gainful employment – may lack extended family and supports – often dependent on partners for sponsorship, fear deportation and losing children, deportation – threat of deportation – woman may have experienced discrimination and racism and therefore reluctant to seek help
Women with Disabilities: difficult to leave if abuser is caregiver, barriers to access services, neglect is very prevalent in abusive relationship – while a disability can make it more difficult for women to escape or report, social attitudes towards people are a bigger factor in her increased vulnerability to violence, the ways in which society views people with disabilities affects these women in many ways – viewed and treated as children, considered to be non sexual and not given sex education, caregivers often seen as good people for taking on such a challenge

15. The Number One Question
Why Does She Stay?
More appropriate questions would be…
Why Does He Abuse Her or
What Prevents Her From Leaving

16. She believes he will change Fear Economic Reasons to Stay/Return
Pressure from Community or Faith or Family
Guilt or Self Doubt
Concern for Children
Lack of Community Support
Demands of Family Court Process
Stockholm Syndrome
Abused women leave an average of 8 times before leaving for good
Stockholm Syndrome: emotionally bonding with an abuser is actually a strategy for survival for victims of abuse and intimidation.
Common Behaviours:
Positive feelings by the victim toward the abuser
Negative feelings by the victim toward family, friends, or authorities trying to rescue/support them
Support of the abuser’s reasons and behaviors
Supportive behaviors by the victim, at times helping the abuser
Inability to engage in behaviors that may assist in their release or detachment
Use example of Stockholm Syndrome: On August 23rd, 1973 two machine-gun carrying criminals entered a bank in Stockholm, Sweden. Blasting their guns, one prison escapee named Jan-Erik Olsson announced to the terrified bank employees “The party has just begun!” The two bank robbers held four hostages, three women and one man, for the next 131 hours. The hostages were strapped with dynamite and held in a bank vault until finally rescued on August 28th.
After their rescue, the hostages exhibited a shocking attitude considering they were threatened, abused, and feared for their lives for over five days. In their media interviews, it was clear that they supported their captors and actually feared law enforcement personnel who came to their rescue. The hostages had begun to feel the captors were actually protecting them from the police. One woman later became engaged to one of the criminals and another developed a legal defense fund to aid in their criminal defense fees. Clearly, the hostages had “bonded” emotionally with their captors.
Example: Elizabeth Smart, a 14 year old girl, was kidnapped from her home in Salt Lake City in June 2002 by two members of a fundamentalist polygamist sect, the homeless preacher Brian David "Emmanuel" Mitchell and his wife Wanda Barzee. At first Smart was kept tethered to a tree in a wooded canyon, dressed in white robes, and confined to a twenty-foot long trough with a lean-to over it, but after two months, the couple was able to take the girl with them to restaurants and other public places, her face veiled, and she no longer tried to escape. The trio travelled to San Diego, California and Las Vegas, Nevada, with Smart claiming to be the couple's daughter, but they eventually returned to Utah. By this time, Smart had become so attached to her captors that when she was finally approached by Utah law enforcement officials, who had been searching for her for nine months, she told them that she was 18 years old and Mitchell's polygamous wife. Only when she was shown a picture of herself as she had looked before her abduction did she admit she was, in fact, Elizabeth Smart.[7]
Millionaire heiress Patty Hearst was kidnapped by the Symbionese Liberation Army. After two months in captivity, she actively took part in a robbery they were orchestrating. Her unsuccessful legal defense was that she suffered from Stockholm syndrome and was coerced into aiding the SLA. She was convicted and imprisoned for her actions in the robbery, though her sentence was commuted in February 1979 by President Jimmy Carter, and she received a Presidential pardon from Bill Clinton.
Every syndrome has symptoms or behaviors, and Stockholm Syndrome is no exception. While a clear-cut list has not been established due to varying opinions by researchers and experts, several of these features will be present:
Positive feelings by the victim toward the abuser/controller
Negative feelings by the victim toward family, friends, or authorities trying to rescue/support them or win their release
Positive feelings by the abuser toward the victim
Inability to engage in behaviors that may assist in their release or detachment might
The perception of threat can be formed by direct, indirect, or witnessed methods. Criminal or antisocial partners can directly threaten your life or the life of friends and family
2. we look for evidence of hope — a small sign that the situation may improve. When an abuser/controller shows the victim some small kindness, even though it is to the abuser’s benefit as well, the victim interprets that small kindness as a positive trait of the captor. – can be as simple as a birthday card or one kind word
3. In abusive and controlling relationships, the victim has the sense they are always “walking on eggshells” — fearful of saying or doing anything that prompt a violent/intimidating outburst. For their survival, they begin to see the world through the abuser’s perspective. They begin to fix things that might prompt an outburst, act in ways they know makes the abuser happy, or avoid aspects of their own life that may prompt a problem.
4. In romantic relationships, the belief that one can’t escape is also very common. Many abusive/controlling relationships feel like till-death-do-us-part relationships — locked together by mutual financial issues/assets, mutual intimate knowledge, or legal situations.

17. Common Effects of Abuse-Related Trauma:
• Fearing people and relationships
• Substance misuse and abuse (includes self medicating)
• Difficulty sleeping or over sleeping
• Flashbacks of the abuse
• Dissociation
• Having panic attacks or uncomfortable amounts of anxiety
• Low self-esteem and self-loathing
• Depression
• Repeated experiences of being revictimized (continued abusive relationships)
• Suicidal ideation or suicide attempts
• Nightmares
• Memory Gaps (especially from childhood)
• Self-harm
• Eating Disorders
(Adapted from: What do these signs have in common? Recognizing the effects of abuse-related trauma - CAMH, 2004)

18. Sexual Abuse

19. Adult Sexual Assault
Sexual assault is a crime of power, control and anger. It is one person’s attempt to hurt or humiliate another through sex and/or violence

20. What is Sexual Violence
It is any form of unwanted sexual activity that is forced upon a person without that person’s consent. Sexual Assault can range from unwanted sexual touching to forced intercourse. While most sexual assault are perpetrated against women, both women and men are sexually assaulted

21. Sexual Assault of Women
Is far more prevalent than sexual assault of men
Almost 40% women have reported at least one assault from age 16
Statistical Trends 2006 Ottawa: Statistics Canada, 2006

22. Sexual Assault of Women
Women make up more than three quarters of all reported sexual assaults
Young women ages making up more than half
Majority of all reported sexual assaults on women are perpetrated by men they are acquainted with
Sexual Offences in Canada, Ottawa: Statistics Canada,2003

23. Statistics 25% of women experience unwanted sexual touching
Another 24% experience violent SA
38% SA by husband, partner, boyfriend
54% of girls under 16yrs experience unwanted sexual attention
24% experience rape/coercive sex
17% experience incest
Only 6% SA reported to police – of these, 63% are girls under 18 yrs
Only 1% date rapes are reported
80% of aboriginal women have been sexually assaulted
83% of developmentally challenged women have been sexually assaulted
1 in 7 males SA
Statistical Trends 2003, Sexual Offences in Canada 2003, Canadian Crime Statistics 2003

24. Vulnerable to Violence
Girls and young women
Women living with disabilities
First Nation women
Women of color
Women living in poverty
Women at war

25. Physical Health Effects
Irritable bowel syndrome
Chronic pelvic pain
Vaginal bleeding
STI’s including HIV infection
Urinary Track Infections
Undetected cervical disease

26. Possible Impact of Sexual Violence
Trauma has an impact on the entire person. The possible consequences to sexual violence are exhibited as symptoms within the context of individual experiences. Symptoms are guideposts for intervention to reduce human suffering and to restore well-being for the individual.

27. Impact of Sexual Violence
Rape Trauma Syndrome (RTS)
Post Traumatic Stress (PTS)
Psychological Manifestations
Relationship Manifestations
Alcohol and Drug Use

28. Rape Trauma Syndrome
RTS is expressed in a complex, entangled lifestyle when an individual lacks adequate coping skills or social or medical support, or is subject to ongoing trauma in his or her environment. As time goes on the physical, emotional, social and sexual categories impacted by the sexual assault become less segregated and more intertwined, making the exact nature of a particular problem less obvious.

29. Rape Trauma Syndrome
RTS is associated with risk-taking behavior, increased substance abuse, lowered self-esteem, depression and anxiety and a wide range of physical and sexual dysfunction.

30. Substance Abuse Studies
30.7% of women in a methadone maintenance treatment program had been sexually abused by a partner in the past 6 months and cocaine use increased this violence (EL-Bassel, 2004)
59% of substance abusers had symptoms consistent with PTSD, yet were undiagnosed at the time they were admitted for detoxification and had not received any treatment (Fullivore et al.,1993)
97% of women with PTSD reported one or more violent traumas compared to 73% women without PTSD (Fullivore., 1993)

31. Post Traumatic Stress
Persistent frightening thoughts and memories of their ordeal
Recurring distressing dreams of the event
Feeling emotionally numb
Avoidance of stimuli associated with the event
May not show up until years after the event

32. Psychological Manifestations
Difficulty concentrating, hopelessness, anger, depression, eating problems, decreased self-esteem
Denial
1/3 of rape victims will contemplate suicide
17% actually attempt suicide
1/3 of all sexual assault victims will develop PTS sometime during their life

33. Relationship Manifestations
Problems in relationships – family friends, spouses
Shame and guilt – blaming themselves, feeling different from all other human beings
Social problems – difficulty with trust
Sexual problems - avoidance of sexual activity, decreased interest and desire

34. Substance Abuse
Substance abuse, especially with alcohol, cigarettes and cocaine, is common when victims desire to numb or cope with the pain of sexual trauma
In drug treatment programs, 46.4% of patients had a history of sexual assault as adults and 38% in childhood (El-Bassel, Gilbert, & Fry et al., 2004)

35. Trauma and Substance Abuse
Data collected from substance abusing women from nine treatment centres across Ontario
85.7% of 98 women in her sample were victimized
56.1% adult physical abuse
56.3% childhood sexual abuse
56.1% childhood physical abuse
45.4 adult sexual abuse
Cormier, R, A; 2000

36. Child Sexual Abuse

37. Child Sexual Abuse (CSA)
Child sexual abuse occurs when a child under the age of 16 is used for sexual purposes by an adult or adolescent. It is emotionally abusive and is a betrayal of trust and an abuse of power over the child. Sexual abuse is often accompanied by other forms of mistreatment.

38. Child Sexual Abuse
CSA involves exposing a child to any sexual activity or behavior, whether directly or indirectly. Examples include sexual touching, sexual acts, exhibitionism, pornography and prostitution. The law does not differentiate between the actions performed on a child and those performed by a child.

39. Child Sexual Abuse Historically
Children are responsible for their own molestation
Mothers are to blame
Child sexual abuse is rare
Sexual abuse does no harm
Children always tell
Children feel negatively about the abuser
All abusers are male
There is little impact for the survivor

40. Who are the Victims
Found in all classes and ethno-cultural communities
Children who have physical or mental disabilities are especially vulnerable to sexual abuse
Children who are isolated – little contact with friends, siblings or adults whom they can trust
Some abusers manage to isolate the child by manipulating people or situations

41. Child Sexual Abuse CSA is largely a hidden crime
Children often afraid to report
Often fear consequences of disclosing information
Often convinced no one will believe them
Very young children are unable to articulate or understand their experiences

42. Statistics
Children and youth account for 61% of reported sexual assaults
50% of sexual assaults on children under the age of 6 are perpetrated by a family member
86% of all reported child sexual assaults are perpetrated by an individual known to the child
Strangers are implicated in only 5% of reported child sexual assaults, and the majority of these are against older teens
67% of reported CSAs take place in a private dwelling
Children and Youth as Victims of Violent Crime, Ottawa, Statistics Canada, 2005

43. Internet Child Exploitation
These are relationships initiated online that result in a child or adolescent being lured or misled into a situation that results in attempted or completed sexual abuse or assault or “compliant” sexual activity (“cyber-enticement”)

44. Internet Child Exploitation
Child/adolescent who was sexually abused and photos taken for distribution over the internet
Using online porn images to seduce, groom or desensitize a child/adolescent for the purpose of engaging in sexually abusive behavior with the child/adolescent
Child/adolescent who experiences unwanted online sexual activity
Peer victimization (images shared between peers)
Sexual activity transmitted over the internet via webcam

45. Child Sexual Abuse Decreased self-esteem Depression
Increased risk taking behavior
Dissociation
Poor boundary setting
Substance abuse, including alcohol and prescription drugs
Self-harming behaviors
Suicide

46. Lifestyle of Victims of CSA
Unemployment
Homelessness
Increased risk taking
Incarceration, 55% -73%
Abusive relationships

47. Consent May 1st, 2008 –changes to Age of Consent
Criminal Code was amended
Consent increased from 14 to 16yrs
Close in age exceptions
12-13yrs - no more than 2 yrs older
14-15yrs - someone less than 5 yrs older

48. VICARIOUS TRAUMA

49. Vicarious Trauma (VT)
VT is described as the cumulative transformative effect of the helper working with survivors of traumatic life events

50. Vicarious Trauma
It affects many aspects of the helpers life not just within the professional setting
Includes typical symptoms of PTS
Also encompasses symptoms of disruptive frame of reference, including disruption in identity, worldview, and spirituality

51. Causes of VT
The causes of VT, compassion fatigue, secondary traumatic stress are all connected with providing services and care to individuals who have experienced some form of traumatic event. Sexual assault/abuse and domestic violence are examples of the type of primary trauma that people might experience

52. Personal Impact
Cognitive – Decreased concentration, Decreased self-esteem, apathy
Emotional – anxiety, depression, guilt, fear
Behavioral – Irritable, appetite changes, negative coping, smoking, substance abuse
Spiritual – anger at god, questioning prior religious beliefs,
Interpersonal – loss of purpose
Physical – somatic reactions, headaches, increased heart rate, aches, pains

53. Professional Impact of VT
Low motivation
Changing roles from caregiver to victim
Withdrawal from colleagues
Decrease in confidence
Negative attitude
Poor communication
Faulty judgment
Burn-out

54. Self-Care for Caregivers
Develop own self- care plan
Build on strengths
Make goals that enrich your life
Check out available resources
Commit to replenish yourself
Identify healing activities that work for you