A history of sexual abuse is common in people with mental health problems. A trust set up a training programme to help staff broach this difficult issue with service users
Lois Dugmore, MBA, MSc, BA, RMN, is nurse consultant dual diagnosis; Jacqueline Channell, NP, RMN, is lead nurse for safeguarding; both at Leicestershire Partnership Trust.
Dugmore L, Channell J (2010) Developing a training programme for detecting and tackling childhood sexual abuse. Nursing Times; 106: 8, early online publication.
Childhood sexual abuse can be implicated in a range of mental health problems including depression and anxiety, but often mental health care staff lack confidence in dealing with the issue.
Leicestershire Partnership Trust, which provides mental health, learning disability and substance abuse services, introduced the Department of Health’s violence and abuse training programme, as part of the second wave pilot, to support staff in raising the issue and providing appropriate care.
Keywords Sexual abuse, Drug use, Mental health, Violence
- This article has been double-blind peer reviewed
- Practitioners need to recognise the problem of childhood sexual abuse and ensure they can provide appropriate care, treatment and support.
- Joint working within and across teams with both the voluntary and statutory sector is vital in dealing with disclosures of sexual abuse and domestic violence.
- All clinical staff from healthcare assistants to consultant psychiatrists, need training in assessing clients for the possibility of a history of sexual abuse. They should broach the topic as part of initial assessment and also on follow up assessment
- Training programmes need to be funded and clearly built into staff development. There needs to be a clear audit trail to evaluate results through clinical practice.
Sexual abuse is widely regarded as a contributory factor in mental health problems in later life (see Background box). Despite this, many healthcare professionals do not it as part of their role to identify patients/clients who have experienced abuse. They may be concerned that if they raise the issue it could open up a conversation they feel untrained to deal with. However, mental health and substance use service users who have suffered sexual abuse say they would like the issue to be raised (Department of Health, 2002).
One key issue for drug/alcohol users is that their substance use may increase temporarily during therapy for sexual abuse as a result of discussing sensitive issues, which can then exclude them from services based on certain criteria. The DH (2007) inpatient guidance recommended that clients should have a full assessment in spite of substance use.
As part of the second wave of the DH (2008) pilot programme on violence and abuse. Leicestershire Partnership Trust started to deliver training to 120 acute mental health staff over 12 months. It was rolled out across the trust to all levels and grades of staff from consultant psychiatrists to healthcare assistants. Three experienced practitioners from different backgrounds - drug and alcohol, psychotherapy and safeguarding - delivered the programme.
Each team in the trust was asked to nominate staff members to attend. A number of teams asked to train as a group, which worked well as staff then had the support of their team and the training could address each group member’s specific level of responsibility.
The response to the programme was positive, with 230 staff members receiving training in the first year.
Dealing with disclosures of sexual abuse
Practitioners felt the most difficult issue was not raising the topic but how to deal with clients’ responses. Many said they felt lost, scared, frustrated, angry and unsupported in dealing with this challenge, and that the issue should only be raised once a therapeutic relationship has been developed. However, by that point service users may find it difficult to disclose past abuse.
The trainers addressed staff concerns about clients’ responses by explaining that while few who have experienced sexual abuse want to discuss the details of their case, they do want to talk about how they feel.
It also became clear that practitioners do not see asking about sexual abuse as part of their role, but as part of the responsibility for either specialist services or the voluntary sector.
However, healthcare practitioners have an important role in encouraging those who wish to disclose past sexual abuse, as its long term effects include:
- Relationship problems;
- Post traumatic stress disorder;
- Feeling “dirty”;
- Inability to trust;
- Self harm;
- Addictive behaviour;
- Eating disorders;
- Sleep disturbance;
- Behavioural problems;
- Suicidal attempts;
- Abusing others.
Delivering the pilot programme
The trust already had a successful and well attended sexual abuse forum which had been running for four years, and also had a great deal of expertise in its personality disorder and specialist services. The pilot programme was developed and altered from the DH’s set format to include eight relational positions:
- The unseeing, uninvolved parent;
- The unseen, neglected child;
- The sadistic abuser;
- The helpless, impotently enraged victim;
- The idealised, omnipotent rescuer;
- The entitled child;
- The seducer;
- The seduced.
Each session was adapted to meet the needs of the staff group attending; it was important to include those working with children and adolescents, older people and people with learning disabilities.
Safeguarding issues need to be considered in the context of people disclosing historical sexual abuse and the risks that a perpetrator may continue to pose to others. It was important that the trust was able to demonstrate its expectations for staff to act on these disclosures and that they understood the referral process.
During the training events there were many discussions about how mental health services balance their duty to protect children with the need to maintain what is in many cases a therapeutic relationship with their clients. The trust ensures that supervision systems are in place to support staff with these issues.
The safeguarding adults process was also reiterated when thinking about clients with ongoing abuse issues or when there may have been other vulnerable people in an abusive household. On all training days we provided information on the safeguarding services available from external agencies.
Many examples shared during training sessions showed that domestic violence was often a current issue for people who had experienced childhood sexual abuse, so this topic was also covered during sessions. Finding the right time to ask was paramount (Read 2007) as was how to ask question in a way that would maximise the client’s answer.
We provided emergency helpline telephone numbers for voluntary sector agencies, such as Domestic Violence Integrated Response Project (DVIRP) and Women’s Aid, as well as contact details for the trust multi-agency risk assessment committee.
Time was also devoted to discussing individual concerns and approaches, The training included information about the provision of appropriate care/counselling, treatment and support for clients and additional support for staff.
The issue of sexual abuse was added to the care programme approach documentation with a clause stating that practitioners should not raise the issue until they had received training, but they should consider its importance at assessment.
It was also essential to recognise that some practitioners may have suffered abuse as children and to ensure they had access to confidential advice and support.
Table 1 outlines the main concerns that staff expressed about raising the topic, as well as advice on how to overcome these.
Follow up and feedback
Follow-up after training was offered at local forums for supervision and updates. These were optional at the time but after the pilot attendance at the forums became mandatory for all clinical staff.
Feedback on the programme was positive, showing a willingness to explore issues and to transfer the learning into clinical practice.
It was clear during training that there needed to be joint working within and across teams with both voluntary and statutory sector staff to ensure continuity.
Staff need adequate supervision to be able to raise the issue of sexual abuse. Staff support groups should also be developed.
All clinical staff need training on raising the topic when assessing patients. During the training it was clear that individual teams needed to develop strategies and appropriate ways of broaching the issue for their specific service. It was also apparent that staff did not know where or when to refer clients, so they were given details on referral and services available.
- Childhood sexual abuse is widely regarded as one of the causes of mental health problems in later adult life, and is also associated with drug and alcohol misuse.
- In acute mental health services 60% of service users reported childhood sexual abuse (Department of Health, 2002).
We would like to thank Tracey Alexander, psychotherapist, Leicestershire Partnership Trust, for her help with this article.
Department of Health (2008) Refocusing the Care Programme Approach Policy and Practice Guidance. London: DH.
Department of Health (2006) Dual Diagnosis in Mental Health Inpatient and Day Hospital Settings. London: DH.
Department of Health (2002) Women’s Mental Health: Into the Mainstream – Strategic Development of Mental Health Care for Women. London: DH.
Read J et al (2007) Why, when and how to ask about childhood abuse. Advances in Psychiatric Treatment; 13: 101-110.