The shackles of abuse: unprepared to work at the edges of reason

Mental health challenges facing male survivors of child sexual abuse: Implications for mental health nurses

Child sexual abuse (CSA) is an issue of epidemic proportions in the United Kingdom (UK) and an international public health problem. Evidence suggests that in the UK one in 20 children have been sexually abused, with one in three not telling anyone about it at the time of the abuse. Conservative estimates suggest that around one in six men have experienced sexual abuse before the age of 18. CSA has been correlated with the development of numerous mental health problems, abused men often displaying externalizing behaviours, including substance misuse, 'risky' sexual behaviours, anti-social behaviour, and offending. This article reports on one aspect of a research study focusing specifically on male survivors of CSA and its effect on their mental health. Using narrative research, face-to-face interviews were used to collect the stories of four men who participated in the research. Interviews were audio-recorded and transcribed verbatim. Analysis used a two-phase approach; initially, each narrative was analysed as a whole, with an across transcripts analysis then being carried out identifying shared themes emerging from the individual stories. Whilst findings from the second phase of the analysis identify four themes, it is the theme of 'Blocking the Memories' that is the focus for this article. Making a valuable contribution to existent knowledge regarding the experiences of men who were sexually abused as children, this article will help to inform mental health practitioners who are likely to deliver care to male survivors of CSA.

Learning How to Ask - Does a one-day training increase trauma inquiry in routine substance use disorder practice? Results of a cluster-randomized controlled trial

AIMS

To examine the effectiveness of a one-day skills training program for increasing trauma inquiry in routine substance use disorder treatment.

DESIGN

Cluster-randomized two-armed controlled trial, with 12 substance use disorder (SUD) organizations operating 25 counseling centers, randomly assigned to training in trauma inquiry (13 counseling centers of 8 SUD organizations) or no training (12 counseling centers of 4 SUD organizations).

SETTING

SUD counseling centers in Northern Germany.

CASES

N = 5204 SUD counseling services.

INTERVENTION

The professionals assigned to the intervention group received a one-day training in trauma inquiry plus a 1.5-hour refresher session 3 months later. Professionals in the control group received no training.

MEASURES

Over a 12-month period, professionals documented for each counseling service whether they asked the client about four traumatic events: physical abuse, emotional abuse, sexual abuse and neglect.

ANALYSIS

Primary outcomes were rates of asking about physical abuse, sexual abuse, emotional abuse and neglect in the 6 months after training. These were compared across conditions, while adjusting for baseline probabilities in the 6 months before training, using mixed-effects logistic regression.

FINDINGS

In the 6 months after training, the rate of asking about physical abuse was 18% higher in the SUD counseling services of trained professionals, relative to services of untrained professionals (OR = 1.18, 95% CI = [1.01-1.37, p = .035]). No effect was found for asking about sexual abuse, emotional abuse and neglect.

CONCLUSION

A one-day training program in trauma inquiry, combined with a brief refresher session, was effective in increasing inquiries about physical abuse in routine counseling practice. The training was ineffective in increasing inquiries about sexual abuse, emotional abuse and neglect. The effectiveness of a one-day training of trauma inquiry might be increased by a longer training, or by combining it with additional elements, such as ongoing supervision.

Supporting the Sexual Intimacy Needs of Patients in a Longer Stay Inpatient Forensic Setting

PURPOSE

To explore perceptions of nurses and patients regarding sexual intimacy in a long-term mental health unit.

DESIGN AND METHODS

Qualitative exploratory design including in-depth semi-structured individual interviews with 12 registered nurses and 10 long-term patients of a forensic mental health hospital.

FINDINGS

The theme of supporting sexual intimacy was identified and described in this paper and included the following subthemes for nurses: It depends on the setting, need for guidelines and consent, and for patients-it depends on the setting; and need for support.

PRACTICE IMPLICATIONS

The findings suggest that current guidelines regarding sexual intimacy in acute inpatient settings may not be appropriate in long-term facilities, with a need for guidelines to specifically address this setting. Furthermore, support for sexual intimacy needs of patients was identified as a strong need for patients and they believed not currently met. Nurses have an important role to play as part of their holistic approach to care and barriers to providing this aspect of care must be overcome to ensure patients' rights are respected.

Exploring sexual risks in a forensic mental health hospital: perspectives from patients and nurses

Patients utilising forensic mental health inpatient services experience a range of sexual risks, including vulnerability to sexual exploitation and exposure to sexually transmissible infections. However, there is a paucity of research exploring the issue of sexual risks from the standpoint of patients and the nurses who work closely with them in inpatient secure settings. This article presents findings from a qualitative exploratory study, which investigated the views of patients and nurses about sexual relationships in forensic mental health settings. Risk was a major theme arising from the data and is the focus of this article. Subthemes from nurse participants included sexual safety, sexual vulnerability, unplanned pregnancies, and male sexuality issues. Subthemes from patients included risks associated with sexual activity, access to information and sexual health care, unplanned pregnancies, vulnerability, and male sexuality issues. Knowledge about these sexual risks by patients and nurses were well articulated, however information and assistance were considered by patients to be less than satisfactory in improving their knowledge or in providing the support they considered important to reduce sexual risks. The issue of risk needs to be addressed, and nurses would be well placed to contribute; however they require education to improve their ability to provide sexual health education to patients along with strategies to ensure patients receive the support and services they require to reduce their exposure to sexual risks.

Supporting the development of interpersonal skills in nursing, in an undergraduate mental health curriculum: reaching the parts other strategies do not reach through action learning

The centrality of therapeutic relationships is considered to be the cornerstone of effective mental health nursing practice. Strategies that support the development of these skills and the emotional aspects of learning need to be developed. Action learning is one such strategy. This article reports on a qualitative research study on the introduction of Action Learning Sets (ALS) into a Pre-registration Mental Health Nursing Programme. This teaching and learning methodology was chosen to support the emotional aspects of learning and mental health nursing skills. Four themes were identified: developing skills of listening and questioning in 'real time', enhanced self-awareness, being with someone in the moment--there is no rehearsal and doing things differently in practice. Students and lecturers found the experience positive and advocate for other Pre-registration Mental Health Nursing Programmes to consider the use of ALS within the curriculum.

Nature of child sexual abuse and psychopathology in adult survivors: results from a clinical sample in Scotland

The relationship between history of childhood sexual abuse and psychopathology in adult life is well established. However, understanding of the mechanisms by which abuse exerts its effects is limited. To our knowledge, this is the first study which investigates the relationship between a wide range of sexual abuse characteristics (i.e. age at onset, frequency of assaults, number of perpetrators and their relationship to the victim) and the severity of psychopathological disorders in a large sample of adult child sexual abuse (CSA) survivors who attended a specialist Psychotherapy Service for CSA survivors. CSA survivors in our study experienced severe sexual assault(s) in their early years and presented with severe pathology which could suggest a strong causal link. However, none of the examined trauma characteristics significantly predicted severity of psychopathology. This may suggest that for severely disordered, treatment-seeking CSA survivors post-abuse psychopathology could be caused by other factors. The study adds to the growing body of evidence suggesting that CSA effects may be dependent on factors which are not necessarily related to the nature of sexual abuse. The study findings will help improve clinicians' insight into the determinants of psychopathology.

Nurses' perspectives on the care of adults with mental health problems and histories of childhood sexual abuse

Despite growing awareness and evidence linking childhood sexual abuse (CSA) to numerous ongoing health problems in adulthood, the integration of this knowledge into nursing practice remains inconsistent. This article reports the results of a study that explored nurses' perspectives on, and experiences with, providing care for adults with mental health problems who may also have histories of CSA. Nurses' views underscore the challenges and complexities involved when providing care for this population. The themes of nurses' knowledge and comfort levels, ethical practice, patient care considerations, and system issues are used to discuss nurses' understandings, perspectives, and experiences.

Talking about sex as part of our role: making and sustaining practice change

Sexual issues are common for consumers of mental health services and have many adverse consequences for quality of life as well as impacting negatively on the mental illness itself. Nurses in mental health settings are well placed to assess for the presence of and provide interventions for sexual concerns. To date, little research has been undertaken to explore nurses' attitudes and whether sexual issues would be accepted as part of their care. This paper presents findings from the third stage of a qualitative, exploratory research study with mental health nurses working in an Australian mental health service. The findings from the first two stages suggested that the participants had tended to avoid discussion of sexual issues, but a brief education intervention had produced a greater willingness to address sexual issues as part of care. The aim of the third stage was to determine the degree to which changes in practice had continued over time. Two main themes that emerged from this data were: (i) holism, from rhetoric to reality; and (ii) part of what I do. Addressing sexual issues became part of practice, a change sustained 2 years following the intervention, because participants recognized its importance for holistic nursing care.

The 5-As framework for including sexual concerns in mental health nursing practice

Available evidence informs us that sexual health concerns of consumers are commonly avoided within mental health services. This paper describes the findings of a qualitative exploratory research project. This research was conducted in three stages, all involving in-depth interviews with 14 nurses working in a mental health setting. Stage 1 involved an exploration of participants' views about including sexual concerns in their practice and included an educational intervention designed to encourage sexual inclusivity in practice. Stage 2 involved follow up interviews 4-6 weeks later to discuss the effectiveness of the intervention and whether practice change had resulted. Stage 3 was conducted two years later with the aim of determining the extent to which practice changes had been sustained. The themes emerging throughout the research emphasised five main stages in the nurses' experience: avoidance; awareness; applying; approval; and acknowledgement. Avoidance of the topic was commonly noted in the early stages of the research. The education program led to awareness raising of sexual concerns and approval towards the importance of this area to which lead to applying it to practice. This ultimately resulted in acknowledgement of the need for sexual concerns to become part of mental health nursing practice. These five stages are represented in the Five A's for including sexual concerns in mental health nursing practice, the framework developed by the first author.

Mental health problems and medically unexplained physical symptoms in adult survivors of childhood sexual abuse: an integrative literature review

People sexually abused in childhood are at higher risk than non-abused people of medically unexplained symptoms such as irritable bowel syndrome or chronic pain, with mental ill health and high healthcare use. Friction and frustration, with high, unproductive healthcare costs, can often develop between these patients and health-care professionals such as general practitioners and nursing staff. The aim of this integrative literature review was to seek a sound evidence base from which to develop helpful interventions, improve relationships and identify gaps in knowledge. It found some theories about interconnections among childhood sexual abuse mental health and medically unexplained symptoms, such as 'somatization' or 'secondary gain', were used prejudicially, stigmatizing survivors. Conflicting theories make more difficult the search for effective interventions. Researchers rarely collaborated with sexual abuse specialists. Emphasis on identifying key risk factors, rather than providing support or alleviating distress, and lack of studies where survivors voiced their own experiences, meant very few targeted interventions for this group were proposed. Recommendations to enable effective interventions include making abuse survivors the prime study focus; qualitative research with survivors, to assist doctors and nursing staff with sensitive care; case histories using medical records; prospective studies with sexually abused children; support for the growing field of neurobiological research.

Ordinary people, extraordinary voices: The emotional labour of lay people caring for and about people with a mental health problem

Many attempts to reduce the stigmatization of people with mental illness have often been predicated, based on the desire to persuade the public that people with mental illness are 'ill' in the same way as people with medical conditions. This paper presents one aspect from the findings of a study that examined the ways in which lay people perceived mental health and illness. Data are drawn from the discussion of the roles and experiences of different non-mental health professionals who cared for and about people they met in their everyday employment. In this paper, we argue that central to these roles is the importance of listening to people in an arena which is non-statutory and without judgment. We demonstrate that people use popular sectors when they are unsure of the problem they have, or they are reluctant to refer themselves to the professional sector. The paper presents narrative extracts illustrating the emotional labour operating in each participant's role and the extent to which they provide support for their client's emotional and psychological well-being. The implications for mental health nursing are discussed in relation to working with and alongside people experiencing mental distress, in relation to 'ordinary human qualities'.

Health consequences of childhood sexual abuse

PURPOSE

This article provides a summary for advocacy, court testimony, assessment, treatment, prevention, and further research studies in the field of childhood sexual abuse.

FINDINGS

A literature review identifies the psychiatric, social, and disease disorders to which this population is predisposed. Adult survivors experience more depression, obesity, autoimmune disorders (irritable bowel syndrome, asthma, fibromyalgia), eating disorders, and addictions.

PRACTICE IMPLICATIONS

A holistic perspective allows understanding of health consequences for survivors. A model through which to consider these phenomena is presented.

CONCLUSIONS

The long-term consequences of childhood sexual abuse must be assessed and addressed by healthcare professionals.

Jury selection in child sex abuse trials: a case analysis

Child sex abuse cases have been the target of considerable psycho-legal research. The present paper offers an analysis of psychological constructs for jury selection in child sex abuse cases from the defense perspective. The authors specifically delineate general and case-specific jury selection variables. General variables include authoritarianism, dogmatism, need for cognition, pretrial knowledge, and race/socioeconomic status. Case-specific variables include sexual attitudes, homonegativity, juror abuse history, and beliefs about children. The paper also provides a factual background of a representative case, incorporates relevant case law, identifies sources for voir dire and juror questionnaire items, and discusses lessons from the primary author's first experience as a trial consultant for the defense.

Mental health consequences of child sexual abuse

Survivors of child sexual abuse (CSA) can experience a variety of long-term mental health effects on their life trajectory, which brings them to the attention of mental health services. It is vital that the mental health nurse remains aware of the mental health consequences of CSA and receptive towards patients' efforts to disclose a history of CSA. Moreover, fundamentally, the mental health nurse should endeavour to consider his/her own personal feelings on this emotive subject. This article explores the mental health effects of CSA on pre-adolescent children, adolescents, and the long-term effects of CSA into adulthood.

Painting the landscape of emotionality: colouring in the emotional gaps between the theory and practice of mental health nursing

As mental health nurses acquire and utilize knowledge for practice, both emotion and learning become interrelated, interactive, and interdependent aspects of personal functioning and professional practice. Emotion and learning in combination are powerful sources of meaning and direction. This paper explores how, in addressing these important aspects of 'becoming' and 'being' a mental health nurse with students, the medium of painting was used to facilitate the exploration of their self in relation to others encountered in recent clinical practice. Broad principles of psychoanalytic theory are used in analysing the experiences depicted in the student paintings, and their explanatory accounts, in order to explore the emotionality of mental health nursing and the complexities of addressing this within current educational processes. What is revealed is that in the uncertainties of everyday clinical and educational practice, working and learning in the place between knowing and not knowing can give rise to unconscious defence mechanisms being used to achieve emotional homeostasis. This paper argues that while working and learning in this hinterland can sometimes be experienced as being threatening and anxiety provoking, it is also a place for personal and professional development and growth. The tutor's role in facilitating such opportunities for growth is seen as being crucial. However, this will require tutors to actively engage in critical reflection in and on their educational practice in order to better understand and use their authentic self in more effectively supporting the student.

Ideology of nursing care in child psychiatric inpatient treatment

Research on nursing ideology and the ethics of child and adolescent psychiatric nursing care is limited. The aim of this study was to describe and explore the ideological approaches guiding psychiatric nursing in child and adolescent psychiatric inpatient wards in Finland, and discuss the ethical, theoretical and practical concerns related to nursing ideologies. Data were collected by means of a national questionnaire survey, which included one open-ended question seeking managers' opinions on the nursing ideology used in their area of practice. Questionnaires were sent to all child and adolescent psychiatric inpatient wards (n = 69) in Finland; 61 ward managers responded. Data were analysed by qualitative and quantitative content analysis. Six categories -- family centred care, individual care, milieu centred care, integrated care, educational care and psychodynamic care -- were formed to specify ideological approaches used in inpatient nursing. The majority of the wards were guided by two or more approaches. Nursing models, theories and codes of ethics were almost totally ignored in the ward managers' ideological descriptions.

Passive patient or engaged expert? Using a Ptolemaic approach to enhance mental health nurse education and practice

This discussion paper seeks to explore an approach that metal health nurses can adopt that ensures the patient is at the centre of training and professional development opportunities. Although nurse training and education is shaped by practice and theory, the lived experiences of the patients as an educational resource often become lost in the milieu of 'doing' nursing. We argue that in addition to theoretical knowledge and practice knowledge, there is the need to harness the equally important patient experience knowledge. Drawing upon Ptolemaic concepts, this paper explores the potential tensions for mental health nurses resulting from the imbalance in power when engaging in therapeutic relationships with patients. It is argued that in order for mental health nurses to become more effective, they need to learn how to relinquish some of their power, even where this gives rise to uncomfortable tensions for the nurse. Such tensions result from the centrality afforded to theoretical knowledge and ritualized practice that underpins nursing and the difficulties this may cause for many nurses in accepting the value of patient experience as a primary source of knowledge. The difficulties of adopting this approach point to a need for mental health nurses and nurse educationalists to take a more reflexive approach to their patient encounters and within their encounters with each other.

Bordering on insanity: misnomer, reviewing the case of condemned women

In the UK, there have been calls to develop gendered specific mental health services for women in an attempt to ensure privacy and dignity are achieved as and when women come into contact with services. This is a largely rhetorical policy objective. There are more fundamental factors affecting women's experience of mental health services that need addressing. This paper explores these issues in the context of mental health care for women who have been 'given' the diagnosis of borderline personality disorder (BPD). Borderline personality disorder effects 2% of the adult population, 75-90% of those diagnosed being women. This diagnosis continues to present considerable conceptual and therapeutic challenges for all of those involved in mental health services and it remains a categorical label that evokes a wide range of conscious and unconscious responses in mental health nurses. The paper argues that mental health nurses need to recognize the defence mechanisms involved in working with individuals who are often difficult to work with. It is only when mental health nurses can embrace and acknowledge the person in the context of their life, that the pejorative and disabling consequences of the BPD label can be eliminated, ensuring the individual's story is heard and not that which is often a pre-constituted account accompanying this diagnosis.