Beyond survival: resource for organisations working with child abuse survivors

Part One: Introduction

Between May and December 2017, a group of funded projects developed resources focused on sustaining the impact of survivor support organisations. The group’s aims were:

• To help Scottish Government, funded organisations and their stakeholders to understand the impact of survivor support services.
• To develop practical resources to help funded groups – and the wider survivor support sector – to assess, prepare for and improve their sustainability.
• For organisations – or their impact - to be sustained in the long term.

About sustainability

To some extent, sustainability is a myth. There is a common belief that once something has been funded it can be continued without further resources or input. In reality, nothing is self-sustaining. And nothing is sustainable without fresh inputs and new influences. Sustainability can exist, but it is a journey not a destination.

Another myth is that sustainability is about survival and staying the same. This guide emphasises the need to continue listening, learning and adapting. Things change, and so must we. Your organisation’s core purpose might not change, but organisations must evolve or they’ll lose relevance and be left behind.

Finally, sustainability isn’t just about organisations or their services. It can also be about impact. Rather than asking ‘How can we sustain our service?’ we need to start asking ‘Who does the service belong to?’, ‘How can we make a lasting

difference?’ and ‘Are we doing everything we can to develop capacity and reduce dependence on our services?’.

For these reasons, we define sustainability as ‘The capacity to make a lasting difference’ [1]

Group members

The projects who created this guide represent a variety of perspectives: large organisations and small; local and national; specialist and generic. In this way, we aimed to make the resource as representative as possible of a range of approaches.

Flora Henderson	Future Pathways
Lorraine Thomson and Helen Provan	Glasgow Council on Alcohol
Lorraine Sorley	Health in Mind
Elaine Wroe	Mind Mosaic Counselling and Therapy
Angela Gribben	Moira Anderson Foundation
Dawn Fyfe	SAY Women
Julie Crawford	Scottish Government Survivor Support Team
Willie Manson	Stop It Now Scotland
Laura Herculson	Survivors of Sexual Child Hood Abuse Information and Resources
Traci Kirkland	Wellbeing Scotland
Graeme Reekie	Wren and Greyhound (group facilitator)

We would also like to thank the following people for providing expert peer review of the resource:

Catherine Alexander

Sandra Ferguson, NES Trauma Training Framework Team

Jill Fraser, Inspiring Scotland

Catriona Henderson, Corra Foundation

Linda Hill, Trauma Training in Scotland

Allison Mathews, Big Lottery Fund

Monika Sharma, Voluntary Action Fund

Vikki Milne, Survivor Support, Scottish Government

Katie Wotherspoon, Survivor Support, Scottish Government

Our hopes for the resources

We want our resources to help facilitate conversations about sustainable survivor support. We have designed them to be:

• Open enough to be suitable for a range of organisations.
• Easy to understand.
• Top down: linking to Scottish Government outcomes and strategies.
• Bottom up: Reflecting what survivors say they want and need.
• Clear: helping survivors support organisations to describe and promote themselves.
• Challenging: allowing organisations to question themselves.
• Encouraging and empowering: with positive messages – sustainability is a major challenge, but we can make a lasting difference by working with survivors, services, funders, commissioners and policy makers.
• Honest: About the challenges of finding for money and resources to support survivors who are missing out on support.
• Focused: on sustainability in survivor support.

Note: Although it was designed for and by survivor support services in Scotland, the guide is likely to be useable or adaptable in other countries and settings.

How to use this guide

The guide is designed to help facilitate conversations, not to be used as a tick list. Sustainability is a journey not a destination, so it is important to involve other people and take action. Rather than reading or using the whole guide, we would encourage you to select relevant parts to use within your organisation or teams, for example during team meetings, away days, conferences, board meetings, or strategic planning events.

It can also be used to facilitate conversations with external stakeholders, partner organisations, funders, commissioners and policy-makers. For example, is there joined-up support for survivors locally? Where do survivor support services fit into strategic commissioning plans? How can local or national funding and policy contexts improve services’ sustainability?

Involve survivors in these conversations. As the experts in their own lives, they will help to make your work more inclusive, informed and relevant. This ensures your service reflects the needs and aspirations of survivors.

Tips:

• Don’t wait too long – the time to start thinking about sustainability is NOW! Don’t wait until the end of a project or funding period is in sight.
• Use the self-assessment to identify strengths to build on, and weaknesses to address. Use this to create an action plan, prioritising issues.
• Take action – you will learn a lot from a self-assessment, but draw conclusions and take action on them. Once you’ve made an action plan, implement it and review it.

Definitions:

Child abuse and child sexual abuse are complex, systemic and potentially overwhelming problems, but preventable ones, and ones which it is vital to address. They are everybody’s business and there are things we can all do. Different contributions from different types of organisations, services and communities must be recognised and valued. We therefore offer definitions of common terms below to help people who work in services feel better able to understand and act on them.

Survivor – A person who experienced abuse in their childhood.

Abuse – Abuse can take a number of forms; emotional/verbal, physical and sexual, often within a relationship, usually with someone who you know. Examples include childhood sexual abuse, physical or psychological abuse and neglect [2] .

Trauma – An event, series of events or a set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening [3] .

Trauma Informed – Understanding and responding to the issues that can arise for survivors of childhood abuse. ‘Trauma-informed practice is not designed to treat trauma related difficulties. Instead it seeks to address the barriers that those affected by trauma can experience when accessing the care, support and treatment they require.’ [4]

Trauma-specific services are specialist services offering specific care, support and interventions for the consequences of trauma. They may also take a role in informing, supporting and supervising trauma-informed services.

Triggers – Anything that causes survivors to relive experiences of trauma, retriggering an emotional or physical reaction to a past event or situation.

Adverse Childhood Experiences – A group of traumatic and adverse experiences in childhood which can lead to increased risk of long term impacts on physical and mental health as well as social consequences for some, particularly when several of these experiences are part of someone’s early life. [5] (For more information, see Appendix 2)

For more in depth information and guidance we strongly encourage readers to refer to the knowledge and skills framework Transforming psychological trauma produced by NHS Education for Scotland. Most survivor support work follows this framework and the ‘phase-based approach’ it contains.

There is no ‘typical’ survivor – anyone can be affected by childhood abuse and survivors should not be defined by their past experience. Survivors are often strong and resilient contributors to community and organisational life. Survivors can be the nurse in your local hospital, the lawyer standing in the courtroom, the homeless person on the street or the person serving on the till in your local supermarket.

At the same time, reliving the traumatic experiences of abuse (e.g. through triggers or flashbacks) mean that support can be needed at any time. There is still a need for trauma awareness and trauma-informed practice, with services recognising symptoms (like alcohol and drug misuse, self-harm, mental distress) rather than treating them as a cause of the difficulties being experienced.

Abuse and trauma are still taboo subjects in many places, communities, and services. But there can be no doubt that child abuse is a problem of epidemic proportions in Scotland and around the world [6] . See Appendix 1 for more information.

• 1 in 20 children in the UK have been sexually abused [7] , though some research suggests the figure could be much higher.
• 1 in 3 children sexually abused by an adult did not tell anyone [8] , though some research places this as high as 80%
• Over 90% of sexually abused children were abused by someone they knew, not strangers [9]
• Around a third of sexual abuse is committed by other children and young people. [10]

'It is only in recent years that we have come to appreciate the true scale of the sexual abuse of children. The secrecy surrounding such abuse is evident in the fact that only a quarter of children who are sexually abused tell anyone about it at the time. Of these, most tell a family member or friend. Hardly any come to the attention of police, social services or health professionals. In a major study conducted in the UK, 1 in 6 young adults said that they had been sexually abused before they reached the age of 16. It is no exaggeration to describe this as an epidemic, impacting tens of thousands of children every year.' Stop It Now

Examples of survivor support activities and their benefits [11] :

Charities can offer services that can save both local authorities and health services a large amount of money but, how can you evidence that? By going through the process of undertaking a basic cost benefit analysis, you can begin to demonstrate the overall value and outcomes of your service in relation to its costs, as well as the potential savings to the public purse that can be made by you providing that service in the short term.

The process takes time, but it is certainly worth it and by involving your public sector partners in the process, you can garner trust and start real partnerships and collaborations with the public sector to achieve your vision.

The simple case studies that follow show a very basic approach based on the interventions provided by the charities and estimates of the costs avoided as a result of these intervention. It is important to note though that additional assumptions are built in to the findings and there is a risk of bias in the answers, which sceptical funders will be alert to.

Once you have worked out the potential costs avoided over a range of case studies, you can then estimate what the success rates need to be to cover those costs, which can be very powerful in times of scarce funding. Bear in mind that a lot of assumptions are being made in arriving at these estimates, so it’s a good idea to carry out a sensitivity analysis on your key assumptions. What if costs were 50% higher than planned for example? Or if the benefits were only half as big as expected?

For a more detailed explanation of this approach please visit https://www.inspiringscotland.org.uk/hub/approach-cost-benefit-analysis/

Case Study 1: Health in Mind

An adult survivor with chronic pain issues, depression and self-harm. They are in part time employment and have their own home. They engaged with Health in Mind telephone counselling for 18 sessions over a 4-month period.

Potential additional costs implied without support

• If unable to manage chronic pain condition potential loss of employment – Full Housing Benefit and Universal Credit (Job Seeker) for 4 months = £8800 [12]
• Potential for increased GP appointments fortnightly instead of monthly for 4 months = 8 GP Visits @ £90 = £720
• Depression and self-harm could lead to A&E visit = £146, hospitalised for 2/3 days @ £286 per day = £858 – Total £1004
• Self-harm CPN team 2 weeks @ 5 half hour visits per week @ £35 per hour for 2 CPNs = £350
• 8 weeks single CPN follow up @ £35 per hour = £280
• Total potential costs = £ 11,154

Health in Mind support

• 18 sessions at unit cost of £66 per session for 4 Months = £1188
• Client is in receipt of housing benefit assumed for 4 months = £1700

Total support costs = £2,888

Potential Saving = £8,266

• Client reports improvement in state of mind, better able to manage pain and self-harm triggers. They have retained their employment and still have their own home.

Case Study 2: Survivors of Sexual Child Hood Abuse Information & Resources ( SSCHAIR)

Lady A self-referred to SSCHAIR after speaking with another service user. She was experiencing flashbacks, anxiety and depression as well as a flare up of her fibromyalgia. She was struggling with work due to a lack of support and her mental health deterioration, and was on the verge of being signed off. She was living in a difficult situation as the house was in her ex-partners name. She had nowhere else to go, so she had to wait on the housing list while still living in the house with her ex-partner which added to her stress and anxiety. She was also primary care giver to her mother who suffers from various physical ailments and poor mental health.

Potential additional costs implied without support

• Signed off from work for 4 weeks @ £553 per week = £2212
• Weekly CPN support at 1 hr for 6 weeks @ £35ph =£210
• Increased GP visits for mental and physical health, 3 @ £90 per 11-minute visit = £270
• Total potential costs = £2692

SSCHAIR support

Lady A engaged with one to one support with a support worker. She was given a safe space to talk about her relationship break down and the abuse in her childhood. The support worker provided advocacy for Lady A when dealing with housing and workplace meetings. Lady A gained knowledge and increased confidence and felt able to advocate on her own behalf. She felt an improvement in her physical health and a reduction in her depression and anxiety. Due to the input of the support worker she was able to remain at work throughout.

• 7 x 1hr support sessions @ £14.03ph = £98.21
• 3 hrs telephone support @ £14.03 ph. = £42.09
• 3 hrs telephone support @ £0.01 ph. = £0.03
• Total support costs = £140.33

Potential saving = £2551.67

Lady A is now feeling more confident and in control of her life and she is experiencing less anxiety and depression, which has helped to reduce her fibromyalgia symptoms. The estimated value of these outcomes [13] is:

• High Confidence £13096
• Relief from Anxiety and Depression £36706
• Feel in Control of Life £13050