HEALTH RESPONSE TO SURVIVORS of GBV/SV

Federal Democratic Republic of ETHIOPIA

MINISTRY of HEALTH

2016

PA R TI CI PA NT MA NUA L | MO DULE TH R EE

PSYCHOLOGICAL CARE and

PSYCHOSOCIAL SUPPORT

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 Module III: Psychological Care and Psychosocial Support

TABLE OF CONTENTS

Acronyms ..........................................................................................................................................1
Introduction ......................................................................................................................................2
3.1 Learning Objectives ............................................................................................................................. 2
3.2 Psychological and Social Consequences of GBV/SV............................................................................ 2
3.2.1 Psychological Consequences........................................................................................................ 2
3.2.2 Child Sexual Abuse (CSA) and its Effects on the Child Survivor ................................................... 3
3.2.3 Social Consequences .................................................................................................................... 5
3.3 Psychological and Social Interventions................................................................................................ 6
3.3.1 General Principles of Psychological Treatments for Survivors of GBV/SV ................................... 6
3.3.2 Factors that Influence the Psychological Impact on Victims of Sexual Violence ......................... 6
3.3.3 Types and Levels of Psychological and Social Interventions ........................................................ 7
3.3.4 Basic Psychosocial Support: Counseling Survivors of Sexual Violence ............................................ 8
3.4 Referral for Social Services, Rehabilitation and/or Social Reintegration .......................................... 15
Summary of Module III..................................................................................................................... 16
Participant Self-Evaluation ............................................................................................................... 16

Acronyms

CSA Child Sexual Abuse

GBV Gender-based Violence

NET Narrative Exposure Therapy

PTSD Post-Traumatic Stress Disorder

SV Sexual Violence

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Introduction

In Module II you have discussed how to approach survivors of GBV/SV, including history taking, physical
examination, treatment of common injuries and physical/clinical consequences, follow-up care and referral.
However, many survivors who are subjected to GVB/SV suffer from concomitant emotional and physical
injuries and present with mental health problems. Hence it is very important for health care providers to
be equipped with basic knowledge and skill on how to provide first line psychological/mental health care
and/or refer for specialized care as necessary.

3.1 Learning Objectives

By the end of this module, participants will be able to: Core competencies:
Cognitive:
o Explain the major psychological consequences of GBV/SV
- Explain the major psychological
o Describe the core principles of psychological treatments consequences of GBV/SV
to survivors of GBV/SV - Able to provide service for range
o Describe types and levels of psychological and social and levels of psychological and
interventions social interventions
o Provide basic counseling service to survivors of GBV/SV Skill:
o Provide referral for rehabilitation and/or social - Provide counseling to survivors
reintegration of GBV/SV

3.2 Psychological and Social Consequences of GBV/SV

3.2.1 Psychological Consequences

Many survivors who are exposed to gender-based violence or sexual violence will have
emotional/psychological or mental health problems. Although some victims of GBV/SV start recovering
emotionally once the physical injuries from the assault have healed, others will continue suffering from
the emotional wounds and will need more time to recover.
It is important to be able to recognize these survivors and to help them get adequate care. If such help is not
available, there are things that first-line health care providers can do to reduce their patients’ suffering.

Psychological consequences of GBV/SV can be:

− Emotional
− Cognitive
− Behavioral or
− Mental health problems

The table below will help you differentiate and classify the different entities into each category of
psychological impacts. It can as well function as a tool to help in clinical decision-making and
management in assessing, deciding and handling individual survivors. Therefore, health care providers
should follow good clinical practices in their interactions with all survivors seeking care. Moreover, they

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 should be aware of the consequences to enable them distinguish those requiring referral for specialized
psychological care and those to be followed at the first health care.

Mental Health
Emotional Cognitive Behavioral
Problems
• Anxiety • Concentration difficulties, • Inability to sleep • Depression
• Fear • Hyper-vigilance (e.g. when • Avoidance (e.g. some • Suicidal thoughts
• Insecurity people feel constantly alert to survivors tend to avoid • Post-traumatic
• Anger what is happening around certain situations that stress disorder
• Shame them) remind them of the • Anxiety disorders
• Self-hate • Repeated re-experience of the traumatic event) • Eating disorders
• Self-blame traumatic event in the form of • Social isolation • Substance/alcohol
• Withdrawn flashbacks • Withdrawal abuse
• Hopelessness • Nightmares or intrusive • Changes in eating • Body issues
• Helplessness memories (these can be behavior
• Worrying triggered by many different • Substance abuse
• Frustration factors) • Relationship problems
• Denial (difficulties in establishing
• Repression interpersonal
relationships)
• Sexual problems
• Fear of intimacy

3.2.2 Child Sexual Abuse (CSA) and its Effects on the Child Survivor

Child sexual abuse is not uncommon and it is a serious problem. CSA is defined as any sexual activity
with a child irrespective of the consent of the child. The sexual abuse can involve seduction by a beloved
relative or it can be a violent act committed by a stranger.
CSA can take many different forms. Incest is a common form of CSA and is any direct or indirect sexual
contact that occurs between a child and a family member (e.g. a parent, step parent, extended family
member, surrogate parent, etc.). Most incest in families occurs between older male relatives and
younger female children.

Note: Statutory rape is sexual intercourse with a minor, with or without her consent. Children under the
age of 16 years are not termed to have been raped, but to have been defiled.

CSA survivors usually denunciate the following people as the perpetrators: father/father figure;
secondary relatives (i.e. uncle, aunt, grand-father or cousin); peer acquaintance; neighbor; husband of
an early arranged marriage; another person’s boyfriend; a stranger; a sibling; or other.
The acts of CSA may include: fondling a child’s genitals; masturbation; oral-genital contact; digital
penetration and vaginal and anal intercourse. Non-physical sexual abuse in children includes sexual
language, voyeurism and child pornography.

Causes for sexual abuse in children can be linked to e.g. loss of parents, lack of security,
extreme poverty, negative peer influence, poor living conditions, ignorance, myths about
HIV/AIDS and virginity, alcohol and drug abuse and isolation.

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 Effects of CSA on children: children and adolescents who have been sexually abused can suffer
from a range of psychological and behavioral problems, ranging from mild to severe, in both the
short and long term. As for GBV/SV in adults, the impact of CSA varies from person to person
and from case to case.

The problems resulting from CSA include but are not limited to:

- Post-traumatic stress disorder (PTSD)

PTSD arises in response to trauma (e.g. rape).
Psychological symptoms include: distressing re-experiencing symptoms (flashbacks); avoidance of
reminders of trauma and emotional numbness; hyper arousal or loss of memory of what happened;
feelings of jumpiness or panic; feelings of numbness, being in a daze or shock over what happened;
feelings of despair and hopelessness; loss of interest in work, school, socializing or other activities
previously enjoyed.
Physical symptoms include: headaches; muscle and joint pain, twitches or shakiness; stomach ache,
diarrhea, indigestion, heartburn, frequent urination; sweating, dry mouth, cold hands; fatigue and
irritability; substance abuse; sexual dysfunction.
It is important to know that children can also develop PTSD. From the ages 8-10, the symptoms are like
those found in adults. For children under the age of 8 and particularly under 5 years however, the
symptoms are less clear and there are often no overt signs of distress.
Some noted behaviors in children with PTSD include: regressive behavior; new fears; overt
aggressiveness/destructiveness; repetitive play about traumatic event.
One should observe the level of behavior, e.g. assaulting another child vs. mild repetitive play, when
considering the need for treatment.

- Withdrawal and isolation

Children who become victims of sexual violence might avoid being alone with people, such as family
members and friends. Moreover, they could become frightened of people or reluctant to socialize with
them.

- Self-blame and guilt

CSA survivors frequently take personal responsibility for the abuse. When the sexual abuse is done by an
esteemed trusted adult it may be hard for the children to view the perpetrator in a negative light, thus
leaving the survivor incapable of realizing that what happened as not their fault.

Other effects may include: loss of interest (generally and/or in people/activities that the child might
have enjoyed before the incident); increased anxiety; sleeping problems and nightmares; aggression;
self-destructive behavior; feeling “dirty”; decreased school performance; absenteeism from school;
secretive behavior; mood swings; concentration difficulties; complaining of pain while urinating or
having a bowl movement; developing frequent unexplained health problems; suicidal thoughts or
attempts.

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3.2.3 Social Consequences

Social consequences depend on the cultural context of the area in which the survivor lives. In many
cultures survivors are stigmatized and isolated. They, rather than the perpetrator, are often blamed for
the incident. For example, because of the way a girl dressed or the way the survivor acted, the society
might find that her/his behavior and physical appearance provoked the sexual assault. The stigma will
also affect the survivor’s family and wider social network. This may lead to rejection by
partners/families/communities, domestic violence, separation from children, loss of function in society,
loss of job and source of income.

Survivors may also have difficulties to continue a sexual relationship with their partner. This can create
tensions and challenges within the relationship, especially if survivors decide not to disclose the incident
of violence to their partner.

The table below summarizes the social consequences of GBV/SV:

Consequences specific to female survivors Consequences specific to male survivors

• Pregnancy and having to carry the child of a Men and boys affected by GBV/SV may struggle in
perpetrator to term; terms of their self-image and social identity
• Being forced to marry the perpetrator to because of the following:
maintain the family’s honor; • GBV/SV challenges the common views of
• The risk of further violence; masculinity, i.e. men and boys should be
• Not finding a partner; strong, in control and dominant;
• Having difficulties in making a living; • They are afraid of being labeled as homosexual
• Negative attitudes and behavior towards the or bisexual. They are therefore likely to stay
survivor from her own community. silent on the issue and remain isolated.

Consequences specifically to child survivors

• Show sexual behavior inappropriate for her/his age: child survivors might become sexually active
at a younger age than would be considered appropriate; they might be promiscuous; and they
might use sexual language or know information that they are not expected to know at their age.
• CSA survivors (especially males) are more likely to become perpetrators of SV themselves.
• When the perpetrator was a close family member, it might be very difficult for the survivor to
build trustworthy relationships in the future.
• The child might have concentration difficulties which might lead to decreased school performance
to complete absenteeism from school.

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3.3 Psychological and Social Interventions

3.3.1 General Principles of Psychological Treatments for Survivors of GBV/SV

• Survivors of GBV/SV seeking psychological treatments should not be viewed only from the lens
of their problems, but should be seen as a whole person with a unique personality and lifestyle,
and living in a particular context.
• The care giver should be aware of important differences in child and adult sexual assault
survivors and should adapt the interventions accordingly.
• The psychological treatment for survivors of GBV/SV works best when the relationship between
the patient and the service provider is based on trust and understanding. The care provider
needs to have good rapport-building skills and should speak at the level of the patient, keeping
in mind that each patient is unique.
• The care provider should assess the readiness to change in each survivor. Survivors might resist
good suggestions, sabotage their progress, or may not cooperate with the care provider. The
care giver needs to be attuned to when a survivor is more open to change and should guide
her/him towards it.
• The care provider should assume that survivors deeply want change, even if there might be
resistance to varying degrees. The care provider needs to help the survivors unlock the power of
positive change.
• The survivor is the one that has to do the changing. The care provider can only be the facilitator,
or provide the skeleton/framework. The care provider can help the survivor to see new habits,
paths, and ways of being, or more positive directions. However, the patient is the one who must
choose these new options.
• As human beings, each of us is in a continual transition to a better path and to a better way of
being. We might get stuck at a particular level, or even regress. However, the care provider
should work from the principle that problems are solutions waiting to happen and from the
assumption that each moment is an opportunity for potential growth. We should never stop
believing that our problems can be solved or that our growth can continue.
• Keep it simple. Therapy must reflect common sense to the survivors and must be communicated
to them in simple terms and without omitting important information.
• Respect the overarching or super-ordinate principles like the right to Human Dignity, Non-
Discrimination, Self-Determination, and the right to Information, Privacy and Confidentiality.

3.3.2 Factors that Influence the Psychological Impact on Victims of Sexual Violence

• Often the psychological needs of victims of sexual violence are overlooked, even in settings that
offer medical services. With that in mind, health care providers should be aware of the factors
that influence the psychological impact of victims of sexual violence.
These can include:
Whether the victim is a child or an adult, i.e. age
A victim’s socio-biological characteristics

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 A victim’s perception of her/his rights and her/his status
Prior history of incidents, sexual or otherwise
Prior mental health issues
The relationship of the offender to the victim
A victim’s appraisal of the circumstances of the violence (e.g. threat to life, self-blame)
A victim’s coping mechanisms
Positive social support
Perceived and actual response of society, including any formal services approached, to
disclosure of sexual violence
The intensity of violence used during the SV (e.g. assault with a weapon)
The location where the SV took place (whether the place was considered ‘safe’ by the
victim prior to the assault)
A victim’s level of education

3.3.3 Types and Levels of Psychological and Social Interventions

Treatment for psychological disorders relating to sexual violence varies significantly in both approach
and cost. Some treatments have proven effective for treating multiple types of psychological disorders
while others address symptoms related to very specific syndromes.

• Counseling services have proven effective in addressing the psychological needs of survivors of
sexual violence experiencing depression, anxiety or PTSD. Some of the other services include
support groups (i.e. an informal group made up of people with similar problems who and 24-
hour support hotlines.

• Group therapy is a therapeutic process between a counselor and a group of people with similar
problems who share their experiences and thoughts. This approach has also proven to be
effective in addressing symptoms of depression and anxiety. Group therapy is common in places
or environments where social stigma and lack of resources and counselors make it difficult to
receive one-on-one counseling sessions from qualified professionals.

• Cognitive Behavioral Therapy is a short-term, goal-oriented psychotherapy that takes a hands-

on, practical approach to problem-solving. Its goal is to change patterns of thinking or behavior
that are behind people’s difficulties, and thereby change the way they feel. The therapeutic
method works by changing people’s attitudes and their behavior by focusing on the thoughts,
images, beliefs and attitudes they hold (a person’s cognitive processes) and how these processes
relate to the way a person behaves, as a way of dealing with emotional problems.

• Trauma-based approach is a method which is part of a cognitive behavioral therapy currently

considered most effective for treating adults and children with PTSD by directly targeting the
traumatic event. The methodology generally involves retelling the event in explicit detail, a
process that helps the victims to “relive” the experience within a safe environment. One
variation of this trauma-based strategy is called Narrative Exposure Therapy (NET), where the

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 survivor constructs a narration about her/his entire life from birth to the present, exploring the
traumatic experience(s) within this context.

• Art therapy/Play therapy has been used in a range of cultural settings where children have
experienced sexual violence or other traumatic events. The Art Therapy Treatment Intervention
is facilitated in a one-on-one session with children for approximately one to two hours. Children
are encouraged to draw in a way that relate to her/his own unique story in a manner that was
consistent with her/his level of graphic, perceptual, and cognitive development. After
completing the piece of art, the child then retells the event using the drawings. At this point
numerous issues are addressed, including misconceptions, rescue and revenge fantasies, shame
or guilt, traumatic reminders, and coping and reintegration strategies.
Art of play therapy thus creates an opportunity for the child survivor to easily join a therapeutic
process.

Note: This type of intervention is especially important for children, as they express themselves
differently than adults. Indeed, to communicate with children, one has to be able to speak and
understand their three languages: 1) the language of body, 2) the language of play, and 3) the
spoken language.
Moreover, children use four indirect methods to express their feelings: 1) Drawing, 2) Story-
telling, 3) Drama, and 4) Play.

• Psychodynamic psychotherapy focuses on several aspects, such as expression of emotions,

exploration of avoidance of distressing emotions, examining past experiences, identification of
defense mechanisms, and working through interpersonal relationships. An important part of
psychodynamic psychotherapy is bringing the person’s conflict and psychic tensions from the
unconscious into the conscious to encourage healthier functioning.

• Client Centered/Humanistic/Supportive psychotherapy may be provided in individual or group

settings, and allows an individual to share her/his traumatic experience and the symptoms that
resulted from the event. Supportive approaches aim to normalize the experience, instill hope,
increase interpersonal learning, and decrease an individual’s sense of isolation.

• Family therapy is a type of psychological counseling and is usually provided by a psychologist,

clinical social worker or therapist. It helps family members to resolve conflicts.

3.3.4 Basic Psychosocial Support: Counseling Survivors of Sexual Violence

Survivors of sexual violence have multifaceted psychological needs and related cognitive patterns that
should be well understood and taken care of to respond to those needs professionally. Identifying and
understanding the psychological and emotional needs of persons who suffered a traumatic experience is
a very important responsibility and all service providers need to be aware of this.
The response or psychosocial services mainly include psychological counseling, socialization, skill
training and income-generating programs.

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What does psychosocial mean?

• Psycho: The mind (unique feelings, emotions, thoughts, understandings, attitudes and beliefs
which an individual acquires)
• Social: Interpersonal relationships and what goes on in the natural environment.

“Psychosocial” can mean the dynamic relationship between social and psychological experiences where
the effects of one continuously influences the other. Social experiences may indeed lead to
psychological consequences and some individuals with psychological problems will experience social
consequences.

Social experiences that can lead to Psychological experiences that can lead to
psychological problems include: social problems include:
- Loss of loved ones - Anger
- Sickness (of one’s self and/or of one’s parents) - Helplessness
- Physical disability - Frustration
- Lack of basic needs (food, shelter, love etc.) - Mental illness
- Loss of social status - Lack of peace of mind, anxiety
- Domestic violence - Worries
- Suicidal thoughts

Psychosocial versus Emotional Support

Psychosocial support is defined as: “providing compassionate and ongoing psychological assistance for
survivors to heal their emotional pain and sufferings from sexual abuse.”

Emotional support is a “first aid” psychological intervention for understanding the emotional
environment of the survivor and has a healing power for the emotional wounds of child sexual abuse
survivors.

3.3.4.1 Purpose of Psychosocial Support

Needs of survivors of SV:

- Physical needs: food, clothes, shelter
- Emotional/psychological needs: care, attention, security, acceptance, understanding
- Social needs: education, information, health
- Spiritual needs: prayer

After a sexual assault, basic psychosocial support by the general health care provider may be sufficient for
the first 1-3 months, while at the same time monitoring the survivor for more severe mental health problems.
Survivors with more severe mental symptoms need to be referred for specialized mental/psychological
treatment.

- Explain that she/he is likely to feel better with time

- Help strengthen her/his positive coping methods
- Explore the availability of social support

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 - Teach and demonstrate stress reduction exercises
- Make regular follow-up appointments for further support

What is counseling?

Counseling is a professional relationship between a trained counselor and a client. It can be done person
to person or can take place in form of a group therapy.
Counseling can help the survivor to better understand what happened to them, to clarify their views, to
reach self-determined goals through meaningful and well informed choices. Furthermore, it gives the
client an opportunity to explore, discover and clarify ways of living a more satisfying and resourceful life.

3.3.4.2 Conditions for Effective Counseling

In order for counseling to be effective, certain conditions must be fulfilled:

The counselor must always have the client’s best interest in mind; she/he must possess the
professional knowledge and skills to manage cases of sexual violence; enough time should be provided
for each session; the sessions must take place in a separate and private counseling room.

Moreover, the different ground rules in counseling must be respected:

• Rapport/Build a relationship based on trust. Do not rush the process but give it time. You can
for example start discussing things unrelated to the sexual assault in order to ease the situation
and to make the patient feel more comfortable.

• Explain the problem/incident by adapting your language to the language used by the survivor.
For instance, if talking to a child survivor of sexual assault, speak to her/him in a language the
child understands. Use anatomically correct dolls, body language or drawings if necessary for
the child to comprehend the incident and why it was wrong.

Possessing good communication skills and being an attentive listener by following the different steps
(ROLES) is also an essential requirement for effective counseling:

R – stands for Relax: Survivors are more likely to feel comfortable when the care providers are calm and
relaxed.
O – stands for Open: Keep an open posture; particularly regarding your arms (do not cross your arms).
L – stands for Lean: When sitting, lean slightly forward to engender a greater sense of intimacy.
E – stands for Eye: Eye contact is an important part of showing your attention and expressing empathy.
S – stands for Square: Face the survivor square on, with shoulders parallel to her/him.

• Exchange ideas and information: during the session, ask only one question at a time; ask open-
ended and closed-ended questions.

• Decision-making: Know the importance of assessment and decision making procedures in the
counselling process. You cannot decide for your patients but you can help them to make their
own informed and rational decisions (“maximum benefit versus minimum risk”).

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 • Follow-up: Explain to the survivor the importance of patience and time in the healing process
and the value of scheduling at least three follow-up sessions.

• Evaluation: A periodic, comprehensive and systematic review of the intervention, including its
results, is essential to understand whether the intervention is benefitting the patient or whether
a change in the strategy/approach must be made.

A Counselor’s Attitude and Skills

• Professional ethics
Especially in cases of CSA, accepting that the child has been abused is not always easy for the person
that the child talks to. Strategies and skills in handling sexually abused children are thus vital for all care
providers.

• Confidentiality
The principle of confidentiality is fundamentally important with regard to psychological support of
survivors of SV, and is the backbone of counseling. Maintaining confidentiality is essential to build trust
as it creates a safe environment for the patient to speak openly of what happened to him/her.
As for child victims of sexual violence, confidentiality should always be maintained except if it could
potentially harm the child or others. Parents or legal guardians are made aware of confidentiality
requirements but are informed of the counseling progress.

• Flexibility
It is important for the care provider to remain flexible in her/his approach when dealing with survivors
of GBV/SV. Every case of sexual assault is unique because each survivor is different and has different
needs, beliefs, understandings, etc.

• Respect
Showing respect towards the patient is crucial. It helps to build trust and thereby helps the survivor to
open up on what happened to her/him.

• Empathy
Always show and express empathy; try putting yourself in your patient’s position and imagine how hard
it must be for her/him to talk about the incident. Do not be judgmental in your questions and
comments.
Apathy versus sympathy: Apathy is the lack of emotion, motivation or enthusiasm about a person,
activity or object and/or a lack of interest or enthusiasm whereas sympathy is compassion; the ability to
share the feelings of another person and a feeling of sorrow for the suffering of another.

• Understanding
Show the survivor that you understand her/his pain and that you understand the difficulties she/he
must face. Also show understanding when they refuse to disclose any information regarding the assault
or when they need more time.

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 3.3.4.3 Strategies for Handling and Addressing Cases of Child Sexual Abuse (CSA)

• Provide medical support;

• Refer for legal support (e.g. child friendly police unit, free legal aid center, child friendly courts,
etc.);
• Create a safe environment for the child to express her/himself;
• Provide child-friendly and child-sensitive integrated services;
• Provide ongoing counseling support;
• Involve family members if appropriate, social workers, etc.;
• Discuss the possibility of the child attending support groups (e.g. for sexually abused children);
• Assess the need for treatment of STIs;
• Teach children in a language they can understand (using anatomically correct dolls, body
language, drawings, etc.):
o About basic sexual education;
o About their rights and the things they are allowed to do;
o That their bodies are their own;
o That sexual advances from adults are wrong and against the law;
o To say “NO” when their bodies are being touched;
o About the difference between good and bad secrets.
• Do not put different sexes in the same bed room, where possible;
• Parents/guardians should know their children’s circle of friends;
• Teach children important life skills (e.g.: assertiveness);
• Sensitize communities on CSA (including awareness raising and capacity-building).

Interventions in CSA survivors

Child survivors of sexual abuse are often too young to fully understand and realize what happened to them.
In order to help traumatized children to recover from the emotional and psychological stress and to deal with
the situation, it is very important to:
Give the children warmth, love, care, support, even when they do not respond to it.
Give them structure and make them follow a daily schedule.
Find them a parent substitute if their own parents are not present.
Offer them opportunities to talk about what has happened but give them as much time as they need
to open up.
Give them opportunities to express themselves through play, drawing or writing.
Offer them a sympathetic ear.
Give encouragements and avoid too much criticism.

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 3.3.4.4 Strengthening the Survivor’s Positive Coping Methods

After a violent event a survivor may find it difficult to return to her/his normal routine. Encourage her/him to
take small and simple steps. Talk to her/him about her/his life and activities. Discuss and plan together. Let
her/him know that things will likely get better over time. Encourage the survivor to:
Build on her/his strengths and abilities. Ask what is going well currently and how she/he has coped
with difficult situations in the past.
Continue normal activities, especially the ones that used to be interesting or pleasurable.
Engage in relaxing activities to reduce anxiety and tension.
Keep a regular sleep schedule and avoid sleeping too much.
Engage in regular physical activity.
Avoid using self-prescribed medications, alcohol or illegal drugs to try to feel better.
Recognize thoughts of self-harm or suicide and come back as soon as possible for help if they occur.
Return if these suggestions are not helping.

Explore the Availability of Social Support

Good social support is one of the most important protections for any survivor suffering from stress-related
problems. When survivors experience abuse or violence, they often feel cut off from normal social circles or
are unable to connect with them. This may be because they lack energy or feel ashamed.
You can ask:
- “When you are not feeling well, who do you like to be with?”
- “Who do you turn to for advice?”
- “Who do you feel most comfortable sharing your problems with?”

Note: Explain to the survivor that, even if there is no one with whom she/he wishes to share what has
happened to her/him, she/he still can connect with family and friends. Spending time with people the
survivor loves can distract her/him from the distress.

Help the survivor to identify past social activities or resources that may provide direct or indirect
psychosocial support (e.g. family gatherings, visits with neighbors, sports, community and religious
activities). Encourage her/him to participate.

Collaborate with social workers, case managers or other trusted people in the community to connect
her/him with resources for social support such as:
- Community centers
- Self-help and support groups
- Income-generating activities and other vocational activities
- Formal/informal education.

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 Exercise 3.1 Breathing and Progressive Muscle Relaxation Techniques
This breathing and progressive muscle relaxation exercise can be a helpful method to reduce stress.
Your facilitator will take you through this exercise so that you can help survivors, who are stressed,
agitated and anxious to relax using breathing and muscle relaxation technique. This exercise will help to
feel calm and relaxed. You can also use this technical whenever you are stressed or anxious or cannot sleep.
Follow the steps of this practical exercise with your facilitator.
This exercise will take approximately 6 minutes to complete.

1. Slow breathing technique

Step 1 – Positioning: Sit with your feet flat on the floor or sit on a chair. Put your hands in your lap or let
them hang down loosely at both ends if you are sitting on a chair. Close both your eyes.
Step 2 – Relax: Relax your body by shaking your arms and legs and let them go loose. Roll your shoulders
back and slowly move your head from side to side.
Step 3 – Focus your mind: Think about your breath and put your hands on your belly.
Step 4 – Breathe: Slowly breathe out all the air through your mouth, and feel your belly flatten. Now breathe
in slowly and deeply through your nose, and feel your belly fill up like a balloon.
• Breathe deeply and slowly. You can count 1–2–3 on each breath in and 1–2–3 on each breathe
out.
• Keep breathing like this for about two minutes. As you breathe, feel the tension
leave your body.

2. Progressive muscle relaxation technique

In this exercise you tighten and then relax muscles in your body.
• Begin with your toes. Curl your toes and hold the muscles tightly. This may hurt a little. Breathe
deeply and count to 3 while holding your toe muscles tight. Then, relax your toes and let out
your breath. Breathe normally and feel the relaxation in your toes.
• Do the same for each of the following parts of your body, one after the other. Each time,
breathe in deeply as you tighten the muscles, count to 3, then relax and exhale slowly.
Hold your leg and thigh muscles tight…
Hold your belly tight…
Make fists with your hands…
Bend your arms at the elbows and hold your arms tight…
Squeeze your shoulder blades together…
Shrug your shoulders as high as you can…
Tighten all the muscles in your face…

• Now, drop your chin slowly toward your chest. As you breathe in, slowly and carefully move your
head in a circle to the right, and then breathe out as you bring your head around to the left and back
towards your chest. Do this 3 times. Now, go the other way… Inhale to the left and back, exhale to the
right and down. Do this 3 times.
• Now bring your head up to the center. Notice how calm and relaxed you feel.

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3.4 Referral for Social Services, Rehabilitation and/or Social Reintegration

The health care workers who complete the service and ensure the well-being of the survivor should
know and refer her/him for social services for rehabilitation or re-integration. The process of
reintegration into the community or reunification with the family in case of children who have been
placed in temporary homes involves certain procedures and activities. The activities can be divided into
two major categories, namely pre-reintegration and post-reintegration.

Pre-Integration Activities:

• Family tracing and assessment of the social environment

• Developing a reintegration plan
• Preparing the child
• Preparing family or relatives
• Preparing the child for entry into another residential home

Post Family Reunification or Re-integration Activities/Services:

• Post-reintegration outreach monitoring of the family, foster family/care or temporary shelter

• Ongoing support for the reintegrated child
• Provide different capacity-building trainings for the survivors
• Empowerment of the reunified survivor
• The child survivor of CSA reunified with the family shall be provided with the following capacity
building/empowering trainings:
o Life skill training
o Basic business skill training
o Assertiveness

In general, all parties and organizations engaged in psychosocial treatment shall have the following
major roles and responsibilities:

• The organization has to make sure that its staff receives orientation on psychosocial care, and
that each staff member has clearly defined roles and responsibilities.
• The decision for psychosocial intervention is to be taken only by a professional psychologist or
fully-trained counselor from the case management team (if available). With the exception of
emergency and crisis situations, the child has to participate in all decisions regarding
psychosocial interventions on her/his behalf.
• Each organization should make sure that psychosocial interventions addressing trauma, extreme
emotional states, etc. shall be conducted only by professionally trained counselors,
psychologists and psychiatrists, and in accordance with the case management process.

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Summary of Module III

This module focused on the psychological and psychosocial support for survivors of
GBV/SV. These are very important considerations and essential for health care providers
to fully understand. Knowing what attitudes to adopt and what skills are necessary when
dealing with vulnerable survivors is crucial in providing adequate health services.
Also, the issue of CSA and the need to use different strategies when caring for child
survivors is greatly emphasized in order to show how each patient is different and has
different needs.
Moreover, the concept of psychosocial support is explained and various possibilities for
referrals for social support identified.

Participant Self-Evaluation

What did you learn?

What knowledge and skills were you able to improve?

What knowledge and skills still need improvement?

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