Trauma-informed Care and its Significance in Responding to Child Sexual Abuse in India

Abstract

Child sexual abuse is a detrimental experience that could cause deleterious mental-health outcomes in the survivor. Decades of research have revealed the complex nature of child sexual abuse in terms of its characteristics, dynamics, causes, and consequences. Efficacious psychological interventions for managing child sexual abuse-related outcomes in children exist. However, it is now well recognized that interventions alone are not enough for recovery from sexual or any other type of trauma; it requires an entire human service system that is well-informed about trauma and its effects. Given the lack of awareness about the consequences of child sexual abuse and the stigmatization that exists in the Indian context, which significantly contributes toward the evolution and severity of trauma outcomes in victimized children, this paper is an attempt to discuss the relevance of adopting a trauma-informed approach while responding to child sexual abuse.

Introduction

The World Health Organisation ¹ defines child sexual abuse (CSA) as “The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who, by age or development, is in a relationship of responsibility, trust, or power, the activity being intended to gratify or satisfy the needs of the other person. This may include, but is not limited to: the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of child in prostitution or other unlawful sexual practices; the exploitative use of children in pornographic performances and materials.”

CSA is prevalent globally, but much ambiguity remains in terms of the exact prevalence of CSA, mainly due to reasons like a low disclosure rate and different definitions used in research investigating prevalence. However, research points toward a prevalence rate of 8%–31% in girls and 3%–17% in boys globally.^{2, 3}

CSA is intricate in terms of its characteristics, dynamics, causes, and consequences. The experience of CSA is multidimensional in nature, as it is influenced by factors like duration of abuse, frequency, intrusiveness of the act, and relationship with the perpetrator. It has profound effects on the psychological functioning of children. Research shows that about two-thirds of sexually abused children develop psychological symptoms, either short-term or long-term, typically involving behavior problems, emotional problems, interpersonal problems, and issues with school-based attainment. The development of mental health problems following CSA depends on a wide range of factors, like the stresses of abuse itself, the balance of various risk and protective factors present in the child, and the social context in which abuse occurs. Research findings indicate that the effects of CSA are likely to continue into adulthood if not intervened promptly on its manifestation.^4–6

In India, it is estimated that about 18%–50% of children have experienced some form of CSA. ⁷ However, 30%–87% of them do not report the abuse,^{7, 8} chiefly due to fear of loss of dignity, guilt, denial from the community, socio-cultural stigma, mainly if abuse occurred in the family context, a lack of trust in government bodies, and a lack of communication between parents and children about abuse. ⁹ The different risk factors for CSA in the Indian context are being female, poverty, overcrowding, extended family living arrangements, an abundance of street children, a lack of recreational facilities in the family, ¹⁰ low socio-economic status, death of a parent, being born to a commercial sex worker, early experience of CSA, lack of family support, family or personal history of mental health problems, exposure to sexual images in the family context, and lack of sanitation. ⁹ Deb and Mukherjee ⁸ studied the impact sexual abuse had on Indian children and found the presence of depression, anxiety, and low self-esteem in children. Studies have also found a high risk for obsessive-compulsive disorder, temperamental issues, poor social adjustment, lack of trust, insecure relations with parents, low academic performance, sexual risk behaviors, and sexually transmitted diseases. ⁹

Empirical research has proven the efficacy or effectiveness of trauma-specific therapeutic interventions for child survivors of sexual abuse. However, it is now widely acknowledged that trauma-specific interventions focused on the survivor and the family alone will not single-handedly promote recovery, but rather an entire service system that is aware of the impact of trauma on the survivor and therefore seeks to resist or refrain from any practices that would retraumatize the survivor. ¹¹ This approach, which is called a trauma-informed approach to the care of trauma survivors, is adopted by a service system, organization, or mental health service that is involved in delivering service to survivors such that it aims to provide a safe environment whereby its practices do not trigger any re-experiencing of trauma and thus do not negatively affect the recovery of the survivor. ¹² The following section briefly focuses on the concept of trauma-informed care, its principles, core values, systems where trauma-informed care has been implemented, and prerequisites for implementing it.

Trauma-informed Care

The thoughts and efforts for a trauma-informed approach grew out of evidence that the systems or stakeholders involved in mental health services often catered to the needs of individuals without being aware of their history of trauma exposure. This lack of awareness about trauma experienced by the individuals resulted in untreated consequences of trauma that affected the recovery from immediate symptoms or disorders, missed referrals to trauma services, and inadvertently exposed these individuals, who were survivors of trauma, to re-traumatization. ¹³

The first research attempt to investigate the extensive impact of trauma was launched in 1998 by the US government’s Substance Abuse and Mental Health Services Administration (SAMHSA). It conducted a 5-year, multisite study (known as the Women with Co-occurring Disorders and Violence Study) to develop integrated services for women who presented with psychiatric and substance abuse disorders but also had a history of interpersonal trauma. The study focused on developing and testing the effectiveness of a comprehensive and integrated service model that simultaneously addressed substance abuse, mental health disorders, and interpersonal trauma in women. The study compared integrated and nonintegrated treatment models in a sample of more than 2000 women. The study’s results indicated the effectiveness of integrated treatment, as women in this group improved more. These women took part in the planning, implementation, and delivery of their treatment and received treatment for all three conditions. The study demonstrated the complex relationship between violence, addiction, and mental health problems. It also emphasized the relevance of assessing past and present trauma in an individual seeking mental health services. ¹⁴

To be trauma-informed means to (1) know about the trauma history (past and current) of the individual who seeks treatment and (2) understand the role trauma plays in the life of the individual and use that knowledge to design service models that accommodate the vulnerabilities of individuals and provide service in a way that would allow trauma survivors’ participation in treatment. Trauma-informed care is distinct from trauma-specific services in that trauma-informed care aims to develop awareness and inculcate an understanding of trauma dynamics at all levels of the system or organization. It is the context in which trauma-specific services like assessments and interventions are provided. ¹³ SAMHSA ¹¹ describes the trauma-informed approach as follows: “a program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families and staff and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.”

The basic assumptions (the four “R’s”) in a trauma-informed approach, according to SAMHSA ¹¹ are:

Every person in a system or organization has a basic realization of trauma and its impact on individuals, families, groups, or communities. This realization is not restricted to behavioral health services but is indispensable to other service sectors like child welfare, criminal justice, primary health care, peer-run organizations, and community organizations. Lack of understanding is a barrier to successful outcomes for these service providers.

Every person in the system or organization can recognize the signs of trauma, which may be gender, age, or setting-specific.

The system or organization responds by integrating knowledge about trauma into their policies, procedures, and practices, thereby promoting a physically and psychologically safe environment for trauma survivors.

The system or organization actively resists re-traumatization, considering that it can often create stressful environments for trauma victims, which affect recovery. ¹¹

According to Quadra and Hunter, ¹⁵ principles of trauma-informed care essentially involve the following:

To have robust knowledge about the prevalence, nature, and effects of trauma arising from interpersonal violence and its impact on different areas of functioning.

To provide services in a manner that does not undermine trauma survivors. On the contrary, it should promote the physical, psychological, and emotional safety of the survivors.

To embrace a service model that empowers survivors in their recovery process, prioritize the autonomy and collaboration of survivors, and adopt strength-based approaches.

To understand and be responsive to social and cultural factors (gender, race, culture, and ethnicity) that determine the needs and recovery of survivors.

To understand the relational nature of trauma and healing. ¹⁵

These principles uphold the core values of safety (physical and psychological), trustworthiness, collaboration, choice, and empowerment. These values differentiate a trauma-informed approach from traditional services and systems that consider trauma and associated symptoms as separate events requiring a separate source of support, focus on symptom reduction, rely on experts to deal with survivors’ symptoms, and view survivors as vulnerable and needing protection. Contrarily, the trauma-informed approach considers the survivor’s trauma experience as the central event that impacts all facets of life; symptoms are viewed as coping mechanisms to manage trauma-related problems, and everyone in the system is trained to deal with the distress of the survivor. Attempts are made to balance power in relationships and apply strength-based approaches to promote recovery and healing. At the systemic level, the focus is on preventing re-traumatization by creating an environment conducive to healing. In essence, a trauma-informed approach involves reorienting the culture and practices of the system or organization through the lens of trauma and does not necessarily require people to provide treatment for trauma-related symptoms. ¹³

Research shows that trauma-informed care has been implemented at various levels, including systems, organizational, and trauma-integrated interventions. At the system level, trauma-informed care has been implemented in service systems supporting populations like children,^{16, 17} women, ¹⁸ people with mental health problems, and social issues like family violence. At the organizational level, efforts for a trauma-informed approach targeted settings like mental health settings, residential care, and schools. At the trauma-integrated intervention level, knowledge about the effects of trauma and strategies to manage these effects is integrated into a program or intervention that by itself does not target trauma. ¹⁹

Preconditions for Trauma-informed Care

Harris and Fallot ¹³ outline certain preconditions for establishing a trauma-informed approach to care in a system or an organization. These include:

Administrative commitment to change: To integrate knowledge about trauma into service practices, which does not necessarily mean delivering direct trauma services but incorporating a trauma perspective by allocating resources and designing programs to uphold the significance of trauma in survivors’ current issues.

Universal screening: Apart from the main mission, systems or organizations must screen for trauma in individuals, which is to be brief and non-threatening.

Training and education: To educate and train every staff member, despite their professional training, of a system or organization on introductory-level information on trauma and its impact. This training is exclusive of specialized training provided to clinicians responsible for providing trauma-specific services like assessments or interventions.

Hiring practices: To hire workers and clinicians who have basic knowledge about trauma and its effects, where feasible, and engage these trained professionals to educate all other staff in the organization.

Review of policies and procedures: Review the policies and current practices of the system or organization and identify those practices that could re-traumatize a survivor seeking services. ¹³

Implementation of trauma-informed care may appear daunting for systems from the outset. However, it is pertinent to understand that trauma-informed care is an approach that acts as a framework that integrates trauma knowledge and sensitivity to minimize or avoid re-traumatization, improve engagement, and effectively implement existing service models. ¹⁹

Application of Trauma-informed Care in Service Settings Specific to Child Sexual Abuse

In the context of CSA, the application of a trauma-informed approach is relevant in services like health, social care, and criminal justice. Such an approach would involve providing services and interventions that do not inflict further trauma on the child, understanding each child individually, and recognizing the impact of past and present trauma on the child. ²⁰ The implementation of a trauma-informed approach would include multiple systems like child welfare, organizations like residential placement facilities, and mental health services for the child and family. Research evidence indicates that training in a trauma-informed approach helps improve staff knowledge and services, particularly for those with low education levels within the child welfare system, preventing system-induced trauma, and ensuring mental health care for children when indicated. ²¹ A trauma-informed approach can improve communication and engagement between child welfare and mental health care systems, increase referrals for evidence-based treatments, and reduce problematic behaviors and post-traumatic stress in children. ²² Preliminary evidence on the effectiveness of the trauma-informed approach suggests that it improves the well-being of children, reduces caregiver stress, and provides greater placement stability for children. ²³

Trauma-informed Care and Its Implications in Responding to CSA in India

While considering the utilization of mental health services following the disclosure of CSA, empirical research suggests that self-stigmatization (shame and self-blame for children’s abuse) in parents, ²⁴ time and work demands, personal stressors, and accessibility of mental health services are some of the reasons for declining mental health services, even when they are offered at little or no cost. ²⁵ Lack of knowledge about how and where to access treatment, the perception of therapy as irrelevant by caregivers, and involvement in legal and child protection proceedings might obscure viewing CSA as an event with mental-health risk requiring a response. ²⁵

In India, secrecy due to stigma and fear of ostracization prevents disclosure and intervention in CSA. Failure of parents and caregivers to act in the face of noticeable distress in the child prevents him or her from receiving the mental health care that is immensely needed. The legal and medical procedures and interactions with different stakeholders following disclosure often re-traumatize the child and augment the experience of trauma. Consequently, families lose trust and sometimes refrain from seeking justice for their children.^{10, 26} Lack of communication between parents and children about the abuse or resolving to manage the case within the family may prove detrimental to the abused child as his/her difficulties pertaining to mental health go unattended. ²⁷

A study by Sahay ²⁸ notes that family members are reluctant to seek psychiatric or medical help even when they notice that the victimized child has developed unusual symptoms in the aftermath of sexual abuse. Many believe that trauma scars will heal with the passage of time and do not consider mental-health-related services necessary. Parents fear that their children will be labeled as mentally ill, which may adversely affect their future marital prospects. As a result, children are invariably instructed to forget about the trauma and lead a normal life.

In this socio-ecological context, a trauma-informed approach becomes relevant, as the adoption of such an approach would modify the system into one that understands the impact of trauma from a scientific and evidence-based perspective, recognizes and responds to the signs of trauma, and actively resists practices or interactions that lead to re-traumatization of not just victims and their families but also the staff that delivers services. The context of service and care would be defined by physical and psychological safety, trustworthiness and transparency, collaboration, empowerment, and cultural, gender, and historical sensitivity. ¹¹

Conclusion and Future Directions

Availing mental health services in the face of difficulties arising in the aftermath of CSA is sparse in India, mainly due to ignorance about the impact of sexual abuse and the bi-fold stigma of sexual abuse and mental illness. In the background of social, cultural, and systemic factors that interfere with the treatment and recovery of child survivors in India, a transition to trauma-informed care becomes relevant and essential for the system of service providers who act in response to an alleged case of CSA. The trauma-informed approach can be used as the framework within which the existing service model can be implemented, nevertheless, in a context that is highly sensitive to the child’s needs.