ARCHIVED: Chapter 1: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – The handbook as a tool for clinical practice

The Handbook as a Tool for Clinical Practice

Audience and focus

This handbook presents information that will help health care practitioners practise in a manner that is sensitive to the needs of adult survivors of childhood sexual abuse and other types of interpersonal violence. It is intended for health care practitioners and students of all health disciplines who have no specialized training in mental health, psychiatry, or psychotherapy and have limited experience working with adult survivors of childhood sexual abuse. This second edition includes experiences and ideas of both women and men survivors as well as of practitioners from more than ten health disciplines. The Handbook is not meant to encourage health care providers to step outside their scope of practice, nor is it a substitute for the specialized training required to provide intensive psychotherapy or counselling for survivors.

All health care practitioners - whether they know it or not - encounter survivors of interpersonal violence in their practices.

The Handbook is based on extensive interviews, group discussions, and a national consultation process involving adult survivors, clinicians, and mental health practitioners. Direct quotes from participants are included to illustrate selected issues and to connect health care providers in a more personal way to survivors' thoughts and feelings. To our knowledge, the Handbook is the only work in print that has employed a process of bringing adult survivors and health care practitioners together to develop an empirically grounded account of the issues and problems that adult survivors of childhood sexual abuse encounter in health care settings. The empirical basis of the Handbook is found in Appendix A.

An issue for all heath care practitioners

As many as one third of women and 14% of men are survivors of childhood sexual abuse.^31,62,25 Childhood adversity - including sexual, physical, and emotional abuse - is associated with a greater risk of a wide variety of health problems. This means that all health care practitioners - whether they know it or not - encounter adult survivors of interpersonal violence in their practices. Survivors are health care consumers of every age who seek all types of health services, and our hope is that the principles and guidelines of Sensitive Practice will become "universal/routine procedures" in all health care encounters and that all health care consumers¹³⁶ will benefit from them.

The principles and guidelines of Sensitive Practice can be adapted to all health care venues.

Examinations and procedures that health care providers might consider innocuous or routine can be distressing for survivors, because they may be reminiscent of the original trauma. Exclusive focus on the body, lack of control, invasion of personal boundaries, exposure, vulnerability, pain, and sense of powerlessness are common experiences in the health care environment and may be extremely difficult for survivors because they can mirror aspects of past abuse. An appreciation of the dynamics and long-term effects of childhood abuse is the first step toward a better understanding of survivors' needs and responses to care. Sensitive Practice builds on core competencies to help health care practitioners be more understanding of and responsive to the specific needs of adult survivors of violence and abuse.

Although our research focuses primarily on Sensitive Practice in traditional health care settings, health care providers work in widely diverse areas including client homes, rural and remote areas, and school systems. We believe the principles and guidelines of Sensitive Practice can be adapted to all health care venues.

Organization

The Handbook is divided into nine chapters. Readers are alerted (watch for a blue "i" in a blue circle) when the topic addressed in one section is clarified or expanded upon in another section.

• Chapter 1 offers an introduction to terminology and suggestions for using the Handbook.
• Chapter 2 provides basic information about the nature and scope of childhood sexual abuse and health problems associated with a history of childhood sexual abuse to assist health care practitioners to understand the significance of Sensitive Practice.
• Chapter 3 presents information about how experiences associated with a history of childhood sexual abuse may be manifested in health care settings.
• Chapter 4 describes the principles of Sensitive Practice derived from our research; we consider these principles foundational to ethical health care.
• Chapters 5, 6, 7, and 8 outline the guidelines for Sensitive Practice. These guidelines operationalize the principles of Sensitive Practice and are meant as practical suggestions that health care practitioners can incorporate into their clinical practice.
  • Chapter 5 presents those guidelines related specifically to the context of health care encounters.
  • Chapter 6 details guidelines applicable to all interactions between health practitioners and their clients.
  • Chapter 7 offers health care practitioners guidelines for coping with the problems that can occur in encounters with child sexual abuse survivors.
  • Chapter 8 highlights guidelines focused on disclosure of past abuse, especially as it is related to survivor-clinician interactions.
• Chapter 9 explores the contributions which health care practitioners can make to an adult survivor's healing and recovery, and elaborates on the relationship between Sensitive Practice and patient-centred care.
• Chapters 4, 6, and 8 conclude with questions intended to stimulate reflection about the application of the principles and guidelines to health care practices.
• Nine appendices augmenting the text and a bibliography detailing both works cited and recommended readings and resources finish off the Handbook.

Suggested uses of this Handbook

Students, practitioners, and administrators are urged to think about the information on violence and abuse and Sensitive Practice provided in this Handbook, and to reflect on its potential for informing their own practice and workplace policies. Specifically, health care providers should consider:

• How the information applies to them;
• How to implement the principles and guidelines into their practices;
• How they might best respond to the various situations described in the Handbook.

The information in the Handbook applies to everyone in health care environments.

We believe the information in the Handbook applies to everyone in health care environments. Many of the difficulties that adult survivors experience in these environments arise because practitioners who work in them are unaware of the effects of violence on health and health care or because organizational policies and attitudes have not taken this information into consideration. Before dismissing a suggestion as inapplicable to their practices, clinicians are encouraged to reflect upon the following questions:

• What aspects of this suggestion do not apply?
• If a suggestion is not completely applicable, what element(s) of it could be relevant?

The Handbook can be used to help health care practitioners:

• Learn more about the effects of interpersonal violence on health;
• Work more effectively and compassionately with affected individuals;
• Identify and respond sensitively to individuals who are triggered or dissociate in a health care encounter;
• Feel better prepared to work with patients who disclose past abuse;
• Teach administrative personnel and assistants about childhood abuse and its implications for their work;
• Disseminate ideas from the Handbook to colleagues with the intent of creating an integrated and responsive network of care;
• Influence policies and practices within public agencies to be more sensitive to survivors;
• Coach students and colleagues to critically analyze professional practices;
• Reflect on their philosophies of care and how they are expressed in day-to- day practice, with the intent of becoming more ethical, congruent, and sensitive in their work;
• Develop clear guidelines to address their concerns about best practice with a specific patient or treatment procedure.

Terminology

All readers are encouraged to look beyond the terminology to fully consider how the information applies to their own practices.

The following is a clarification of terms the reader will encounter in this Handbook. Many health care providers have various preferences for the words patient and client, clinician, and practitioner, and for the terms they use to describe their work (examination, treatment, etc.). However, all readers are encouraged to look beyond the terminology we use in the Handbook and to see that the information applies to all health care providers.

• Survivor or adult survivor is used instead of victim when referring to adults who have experienced childhood sexual abuse to acknowledge the strength and resourcefulness of individuals who have lived through the experience.²³ Attitudes about the words survivor and victim vary among those who have experienced childhood abuse, as well as among those who work with these individuals.
• Victim is used when referring to the abused child.
• The person seeking care is referred to interchangeably as survivor, patient, client, or individual.
• When referring to violence and abuse we use the terms child sexual abuse, childhood sexual abuse, child abuse, abuse, interpersonal violence, violence, and trauma. In the Handbook, the word trauma is used only with this connotation.
• Recovery and healing are both used to refer to survivors' efforts to address issues related to childhood sexual abuse.
• Clinician, practitioner, health care practitioner, health care provider, and health care professional are used interchangeably.
• Survivor participant refers to survivors who participated in the interviews, working groups, and consultations that were part of this research project.
• Health care practitioner participants and health care provider participants are the health care practitioners who participated in the working groups.
• Assessment and examination reflect initial and ongoing collection and evaluation of subjective and objective information about an individual's health.
• Protocol, procedure, treatment, and intervention describe types of care that health care practitioners offer.
• Appointment, encounter, and interaction are used to reflect ways that health care providers see patients/clients in various health care settings.
• Self care represents the array of actions that a person can take to promote general health and/or as a component in the management of health problems. They range from eating well and exercising regularly to adhering to clinicians' specific recommendations.
• Participants' words appear in italics.

Limitations

The experience and long-term effects of childhood sexual abuse are affected by a complex interaction of factors including: (a) those related to the individual (e.g., genetics, stage of development at which the abuse occurred, personal coping resources); (b) the abuse itself (e.g., frequency, duration, relationship between perpetrator and victim); (c) the presence and quality of social support at the time of the abuse and into adulthood; and (d) those related to the larger environment, including culture, ethnicity, and other social determinants of health. Adult survivors who participated in our studies were recruited from agencies, groups, and individuals offering counselling and support. Thus, they are individuals who have worked or are working towards recovery with the assistance of external support.

Notwithstanding the diversity and uniqueness of these participants, the Handbook cannot claim to address Sensitive Practice for adult survivors with every abuse experience, of every ethnicity and culture, of every sexual orientation, or at every stage of recovery. Similarly, although we have tried to address a wide range of health practitioners working in various settings by incorporating a broad consultation in the research method, we cannot claim to address every aspect of Sensitive Practice for every type of health care practitioner.

While acknowledging these limitations, we believe that this second edition of the Handbook presents a framework for working with adult survivors of interpersonal violence in all types of practice that is both accessible and empirically derived. We hope that health care practitioners will adapt and refine the guidelines as they work with survivors whose unique needs and reactions were not represented by the research participants.