Module 8: Medical and Mental Health Care of CSEC Victims For Community Training Facilitators They (counselors) be too quick to give you medication maybe you just need to talk. I hate when they re looking at their watch, like Time is up. See you next week. - CSEC Survivor Module 8: Medical and Mental Health Care of CSEC Victims 1
Objectives Use a holistic definition of health in referring to healthcare for CSEC victims Understand how CSEC victims develop and exhibit symptoms of Post Traumatic Stress Disorder (PTSD) Time Hardware Materials Handouts Learn appropriate protocols for interviews and physical exams of CSEC victims 90 minutes LCD projector and laptop (for presentations) chart paper markers tape Handout 8.1 Definition of PTSD Handout 8.2 Symptoms of PTSD Handout 8.3 What PTSD Acts Like: A Counselor s Perspective Handout 8.4 Behaviors and Symptoms of CSEC Trauma Handout 8.5 Considerations for Intake Handout 8.6 TEAMSTAT Approach Handout 8.7 Questions that May Provide Further Information About Abuse Handout 8.8 Exam Protocol for CSEC Victims Handout 8.9 Injuries in Assault Victims Handout 8.10 Mini-Case Studies for Medical and Mental Health Intervention Resources Resource 8.1 A Healing Relationship Resource 8.2 Prostitution, Trafficking, and Traumatic Stress Resource 8.3 Addictions and Trauma Recovery Resource 8.4 Self Soothing Techniques Resource 8.5 Sample Intake Forms Resource 8.6 Medical Care of Children of the Night Resource 8.7 The Medical Implications of Anogenital Trauma in Child Sexual Exploitation Module 8: Medical and Mental Health Care of CSEC Victims 2
Agenda 1. Introduction: A Holistic Definition of Health (5 minutes) Chart paper; markers 2. Understanding Post Traumatic Stress Disorder (5 minutes) Handout 8.1 Definition of PTSD 3. Recognizing Symptoms of PTSD in Victims of CSEC (20 minutes) Handout 8.2 Symptoms of PTSD Handout 8.3 What PTSD Acts Like: A Counselor s Perspective Handout 8.4 Behaviors and Symptoms of CSEC Trauma Reference Resource 8.4 Self Soothing Techniques 4. Safety: Setting the Stage for Trust (10 minutes) Chart paper; markers; tape 5. Intake Process (10 minutes) Handout 8.5 Considerations for Intake Resource 8.4 Sample Intake Forms 6. Interviews (15 minutes) Handout 8.6 TEAMSTAT Approach Handout 8.7 Questions that May Provide Further Information About Abuse 7. Exams (10 minutes) Handout 8.8 Exam Protocol for CSEC Victims Handout 8.9 Injuries in Assault Victims 8. Mini-Case Studies: Interviewing and Exam (15 minutes) Handout 8.10 Mini-Case Studies for Medical and Mental Health Intervention Module 8: Medical and Mental Health Care of CSEC Victims 3
INTRODUCTION: A HOLISTIC DEFINITION OF HEALTH Time: 5 minutes Materials: chart paper; markers; tape; slides 1-3 Facilitator s Speaking Points Present overview of Module 8 Review objectives Use slide 3 to present the World Health Organization s definition of health: Slide 3 A Holistic Definition of Health Health is a state of complete physical, mental, and social well-being and not merely the absence of disease -Preamble of the Constitution of the World Health Organization Group Discussion Pose the question: If we wanted to create the most comprehensive definition of health, what other components are important to include? Create a comprehensive definition of health from participants ideas. Facilitators create a list or word web on chart paper of participants responses. Use the example below as a guideline. Module 8: Medical and Mental Health Care of CSEC Victims 4
Example: Comprehensive Definition of Health: - Physical, mental, and emotional well-being - Absence of disease - Safety (physical, emotional) - Shelter - Access to health services and resources - Nutrition and access to healthy foods - Education - Support - Outlets for emotional and/or creative expression - Economic stability/independence - Ability to make healthy choices and decisions Segue to training activities for physical and mental health providers: To truly meet the health needs of CSEC victims, all of these areas of health must be weighed equally and addressed holistically. This takes the partnership of physical and mental health providers. This module will focus on the responsibilities and connections between each professional role. Module 8: Medical and Mental Health Care of CSEC Victims 5
UNDERSTANDING POST TRAUMATIC STRESS DISORDER (PTSD) Time: 5 minutes Materials: Handout 8.1 Definition of PTSD; slides 4-6 Facilitator s Speaking Points Introduce the topic of PTSD and victims of CSEC: It is essential that clinicians who work with commercially sexually exploited children and youth have a thorough understanding of Post Traumatic Stress Disorder (PTSD). Most CSEC victims have survived multiple forms of trauma. Many of the challenges of working with CSEC victims can actually be understood as symptoms of PTSD. Handout 8.1 Definition of PTSD (also slides 5-6) Review each of the points on Handout 8.1 Definition of PTSD, which has information from the American Psychiatric Association. Module 8: Medical and Mental Health Care of CSEC Victims 6
RECOGNIZING SYMPTOMS OF PTSD IN VICTIMS OF CSEC Time: Materials: 20 minutes Handout 8.2 Symptoms of PTSD, Handout 8.3 What PTSD Acts Like: A Counselor s Perspective; Handout 8.4 Behaviors and Symptoms Associated with CSEC Trauma; slides 7-13 Facilitator s Speaking Points Important to note: If you are not a trained mental health clinician, it is not appropriate for you to clinically diagnose any child with PTSD. The intention of covering PTSD in this module is to provide all professionals with a working knowledge of PTSD to better understand the behaviors of CSEC victims and the impact of trauma. Module 8: Medical and Mental Health Care of CSEC Victims 7
Review Handout 8.2 Symptoms of PTSD. Briefly run through and read the list of symptoms: Handout 8.2 Symptoms of PTSD Activity: Snapshots Instructions: 1. Divide participants into small groups of three to six participants to discuss service providers snapshots of counseling CSEC victims. 2. Refer to Handout 8.3 What PTSD Acts Like: A Counselor s Perspective and explain that service providers who work with sexually exploited youth were asked to provide real life snapshots of how symptoms of PTSD manifest in counseling. 3. Assign or let each group choose one or two snapshots from Handout 8.3. 4. Instruct groups to discuss Handout 8.4 Behaviors and Symptoms Associated with CSEC Trauma. 5. Give groups three to five minutes to discuss the questions on slide 13. 6. Groups share their responses while facilitator guides discussion. Module 8: Medical and Mental Health Care of CSEC Victims 8
Slide 13 Working Group Instructions Choose 1 or 2 counseling snapshots to discuss What symptoms to PTSD is the child demonstrating? What behaviors of CSEC trauma should the counselor be aware of? How would you work with this child if he/she was in your office? Reference Resource 8.4 Self Soothing Techniques for participants to use in their practice if they find it useful. Module 8: Medical and Mental Health Care of CSEC Victims 9
SAFETY: SETTING THE STAGE FOR TRUST Time: 10 minutes Materials: Chart paper, markers; slides 14-16 Facilitator s Speaking Points Stress the importance of a practitioner s first engagement with a CSEC victim: The impression a practitioner makes with a CSEC victim upon first engagement is of utmost importance and impacts how well they will be able to properly treat acute health issues or provide long-term care. All do s and don ts of engagement with CSEC victims should be in your mind as we move on to cover more specific approaches for clinicians. Slide 15 First Engagement with Healthcare Providers Can occur in the context of a medical emergency such as assault, for a compulsory or routine check up, or if child comes in with an unrelated health issue (like a fever). CSEC victims likely to either be in crisis, or downplay existing health problems or risks Most CSEC victims will not seek your help, afraid that the information they give you will lead to arrest, placement in social services, return to family, or retribution from exploiter Be alert to warning signs of CSEC when conducting interviews and physical exams with all children! You may not the first person to try to intervene in the child s life. Remain aware of how many interviews or counseling sessions the child has likely been through. Module 8: Medical and Mental Health Care of CSEC Victims 10
Group Discussion Give participants directions for a quick brainstorm for protocol and practices that ensure safety for children: 1. Divide the room in half. 2. Ask one side of the room to brainstorm interview/exam protocols that make a patient feel safe. 3. Ask the other side of the room to brainstorm aspects of an interview/exam that would make a patient feel unsafe. 4. Groups should have two to three minutes to create a list on chart paper. 5. Have groups read off their lists. Note to Facilitator: In the Interview section of this module (section 6) we will return to the concepts of interviewing and engagement. Incorporate examples from this exercise into that section. Module 8: Medical and Mental Health Care of CSEC Victims 11
INTAKE PROCESS Time: 10 minutes Materials: Handout 8.4 Considerations for Intake; slides 17-20 Facilitator s Speaking Points Suggest that organizations/agencies gather information about CSEC on intake forms: We recommend soliciting information about CSEC on intake forms. Youth will give you a lot of information just through routine practices like intake. Agencies should design intake forms with care and put equal consideration into the intake process. Ask a few participants to give some suggestions to the following questions: What are some important things for agencies to consider in order to make intake useful for both agencies and CSEC victims? What are good questions to ask? How should you ask them? Reference Resource 8.5 Sample Intake Forms may be useful for participants to review on their own. Module 8: Medical and Mental Health Care of CSEC Victims 12
Review Handout 8.5 Considerations for Intake participants. Handout 8.5 Considerations for Intake Module 8: Medical and Mental Health Care of CSEC Victims 13
INTERVIEWING AND ENGAGING Time: Materials: 15 minutes Handout 8.6 TEAMSTAT Approach; Handout 8.7 Questions that May Provide Further Information About Abuse; chart paper; markers; slides 21-25 Facilitator s Speaking Points Point out the commonalities between interviewing CSEC victims and any other victim of sexual abuse: Interviewing is an opportunity to get as much information about the child as possible in order to address the child s medical concerns, to address the concerns of the clinician, and to be able to best treat the child and establish the rapport necessary for continued care. Interview and exam protocol for CSEC victims should follow similar protocol for victims of domestic violence, sexual abuse, and/or sexual assault. CSEC victims should be treated with the sensitivity you show all sexually traumatized children. One important protocol is to invite victim advocates to provide additional support for the child. Make connections between strategies learned in previous modules: You may be working with sexually exploited youth and not know it. In this case, you should assume some of the children you work with are victims of exploitation. When a child comes to see you it is an opportunity for intervention and care. Module 8: Medical and Mental Health Care of CSEC Victims 14
Review concepts on slide 22 with group and ask for brief examples/explanation of each from the group. Slide 22 Interviews Keep in mind: Warning signs of CSEC & victim identification The importance of first contact The do s and don ts of engagement What you can do to ensure safety Use slide 23 to introduce the TEAMSTAT approach to interviewing abuse victims: This approach tries to be thorough and recognizes that while victims may not fully disclose their victimization in a clinical setting, the clinician can still get enough useful information in the short term in order to begin building a relationship of trust. Slide 23 TEAMSTAT Approach Interviews Tell them your agenda Express concern Assure normalcy of feelings Medical issues Safety issues Family history, support, runaway tendencies Test and treat presumptively STDs, pregnancy prophylaxis, birth control Access appropriate psychological and legal assistance Timely follow-up Injuries, STDs, birth control, drug/alcohol use, psychological issues Module 8: Medical and Mental Health Care of CSEC Victims 15
The second page of Handout 8.6 TEAMSTAT Approach provides details pertaining to each step of TEAMSTAT. Go through these steps with participants: Handout 8.6 (page 2) TEAMSTAT Approach Module 8: Medical and Mental Health Care of CSEC Victims 16
Group Discussion Refer to Handout 8.7 Questions that May Provide Further Information About Abuse. Ask participants to read silently and when finished turn to their partner for a two-to three-minute discussion about these questions and ones they currently use in their work with CSEC victims using Slide 25 as a guide As a large group, guide participants through a discussion where they will list interview questions that are helpful when interviewing CSEC victims. Write their responses on paper. Remember, CSEC victims may be fearful to tell you about exploitation or may not understand their experience as exploitative or abusive. Use slide 24 to help give participants some critical interviewing tools: Slide 24 Slide 25 Pay attention to: The questions you ask. How you ask them. How many follow up questions you ask. Interviews Ask questions out concern and a real interest in best serving the child, not just to gather information on a form. Make the interview conversational and relaxed to make the child more comfortable With a partner discuss What do you think of the sample questions? Do any get at information you would want from a child? How would a child likely answer the question? What kinds of follow up questions would you ask? Are there any questions on this list you would not ask? Why not? Interviews Module 8: Medical and Mental Health Care of CSEC Victims 17
Review Handout 8.7 Questions that May Provide Further Information About Abuse with training participants. Handout 8.7 Activity: Questions Instructions: 1. Ask participants to turn to the person next to them and ask that person the following questions: Do you feel any of these (the questions on Handout 8.7) get at information you would want from a child? How would they be likely to answer the question? How would thinking about their answer inform how you ask the question, or what follow-up questions you would ask? Are there any questions on this list you would not ask? Why not? 2. Ask three to five partners to share ideas that came up in their conversation. Module 8: Medical and Mental Health Care of CSEC Victims 18
EXAMS Time: 10 minutes Materials: Handout 8.8 Protocol for Exams with CSEC Victims, Handout 8.9 Injuries in Assault Victim; Slides 26-30 Facilitator s Speaking Points Segue from interview to examination. Highlight the following points for participants so they can see the link between a successful interview and an examination: Many professionals use interviews to get information about a child s history and current situation. For clinicians the purpose is dual: to gather information and to prepare for a physical exam. A successful interview gives you the facts you need to assess medical or mental health issues. It is also the time to establish rapport, build trust, and ease a child s anxiety before an exam. Module 8: Medical and Mental Health Care of CSEC Victims 19
Handout 8.8 Refer participants to Handout 8.8 Protocol for Exams with CSEC Victims. Go over each point with participants asking for affirmation or examples as necessary. Handout 8.9 Refer to Handout 8.9 Injuries in Assault Victims for participant to skim through. This handout lists the physical injured that can indicate sexual assault or abuse. Facilitator s Speaking Points Remind Participants that: Not all incidents of sexual assault or abuse result in genital trauma - certainly if the assault happened weeks or days before the exam. Be mindful to look at the child s injuries holistically. Module 8: Medical and Mental Health Care of CSEC Victims 20
MINI-CASE STUDIES: INTERVIEWING AND EXAM Time: Materials: 15 minutes Handout 8.10 Mini-Case Studies for Medical and Mental Health Intervention; slides 31-32 Activity: Mini-Case Studies Instructions: 1. Divide participants into groups of four so that there will be at least three groups per case study. 2. Refer the groups to Handout 8.10 Mini-Case Studies for Medical and Mental Health Intervention. 3. Assign each group one of the three case studies on Handout 8.10. 4. Give groups four to six minutes to read their case study and discuss the questions on slide 32. 5. When groups are finished, ask each group to gather together with the other groups in their section and talk about how they would handle each situation. One person should read the case study out loud before discussing their reactions. Handout 8.10 Mini-Case Studies for Medical and Mental Health Intervention Module 8: Medical and Mental Health Care of CSEC Victims 21
Slide 32 Activity: Mini Case Studies Working Group Questions 1. What are the concerns? 2. What would you ask this child in an interview? 3. What would you look for or be sensitive to during an exam? 4. What would you make sure to do before the child leaves? Facilitator s Speaking Points Use the debriefing questions below to process Module 8 with participants: What kinds of ideas, strategies, or new perspectives did you take from the activities in this module that were designed for someone else s professional role? As a trainer, how can you apply or modify activities that are useful to you but were designed for a very specific audience? This is the end of Module 8. Review objectives and highlight relevant content. Direct participants to complete the evaluation for this module. Module 8: Medical and Mental Health Care of CSEC Victims 22