Past Abuse and Neglect

Past abuse and neglect can negatively impact a person’s health across the lifespan. Historical trauma and adverse childhood experiences are two forms of past abuse and neglect that are particularly relevant to Alaskans.

Historical trauma is a form of past abuse and neglect that can be transferred across generations, impacting entire communities.

• Alaska Native communities have been exposed to generations of violent colonization, forced assimilation, intergenerational loss, and attacks on their culture and wellbeing.
• It is important to keep historical trauma in mind when intervening with a number of other conditions (e.g., substance abuse, suicidality) commonly seen among populations with historical trauma.
• Historical trauma is a factor contributing to high rates of other adverse childhood experiences in Alaska, and an important factor consider for healing and recovery.

See Chapter D-5: Trauma and Posttraumatic Stress for more on historical trauma.

Adverse Childhood Experiences

Adverse childhood experiences (or ACEs ) are common forms of abuse, neglect, and trauma that happen before age 18. The more ACEs a person has experienced, the more likely that person will also experience negative outcomes, such as physical and mental health problems, substance abuse, suicidality, and early death.

ACEs fall into three categories:

• Abuse
  • Emotional /verbal
  • Physical
  • Sexual
• Household challenges
  • Witnessing domestic violence
  • Substance abuse in a family member
  • Mental illness
  • Separation/divorce
  • Incarcerated household member
• Neglect
  • Emotional
  • Physical

ACEs in Alaska

A 2013 study showed that compared to five other states, Alaska had the highest rates of sexual abuse, substance abuse in the home, having an incarcerated family member, and separation or divorce of parents. Alaska was second for other ACE categories, including emotional/verbal abuse, physical abuse, mental illness in the home, and witnessing domestic violence. It is therefore likely that many of your clients will have a history of abuse or neglect. Knowing this can help shape your clinical practice to promote healing and recovery.

Healing and Recovery from Past Abuse and Neglect

At the core of healing and recovery from past abuse and neglect is safety and stability. Safety and stability partially depend on the environment that surrounds a person.

• Safe and stable homes and communities with relatively easy access to all basic needs (e.g., food, water, medicine) are essential for healing and recovery.
• Social support, community connection, and engagement with cultural activities can all promote healing and recovery if aligned with the client’s values.
• Some clients may benefit from brief interventions aimed at improving safety and stability. Others may benefit from counseling or psychotherapy.

Trauma-Informed Care

Based on the high rates of past abuse and neglect in the general population, integrating the principles of trauma-informed care into your practice can help promote healing and recovery for all clients, whether they disclose past abuse and neglect or not. Using the principles of trauma-informed care, you can work with clients to build a sense of safety and security in the clinic and collaborate on how to best help each client in the moment.

Safety and Security

Access to healthy food, clean water, a warm home, and a safe community are basic necessities for healing and recovery. Help individuals and families navigate resources so they are fed, warm, and safe. Work with the client (and caregiver if the client is a minor) to establish a safe social network. Children can benefit from safe, healthy mentors and/or older adults who are supportive and model positive behavior. Adults also benefit from positive social support.

Screening for Past Abuse and Neglect

If you suspect that past abuse and neglect might be an important topic for your client to discuss, you can ask a few questions to open a conversation. The Adverse Childhood Experiences (ACEs) measure is used in some primary care clinics to screen clients for early adversity. Other clinics ask about abuse less formally. Consult with your supervisor and follow your organization’s policies for screening clients for ACEs.

Take time to ask about and clarify the client’s needs. Talking about past abuse and neglect is very difficult for some people and you may be the first person the client has told about her experiences with past abuse and neglect. Many people feel ashamed by their experience. Listen actively and without judgment. Some clients choose not disclose past abuse due to social customs or stigma. Respect clients right to privacy. Don’t push for responses.

You may see a minor client who has been a victim of abuse that was previously reported. The child may have been removed from the home and may be currently living with relatives or a foster family. In these cases, the child may be receiving therapy already.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history related to sensory functioning, development, family, and psychological history.

Treatment Plan, including a history of presenting problem(s) and recommended course of treatment.

General

• Difficulty with day-to-day activities
• Emotional difficulties (e.g., anger, anxiety, sadness, low self-esteem)
• Mental health problems (e.g., depression, eating disorders, PTSD, self-harm, suicidal thoughts)
• Problems with drugs or alcohol
• Sleep disturbance, nightmares, or insomnia
• Difficulty controlling thoughts, repeatedly thinking about the past abuse/neglect
• Confusion, dissociation
• Poor physical health, obesity, or aches and pains
• Struggling with parenting and relationships
• Worrying their abuser is still a threat to themselves or others
• Hypervigilance
• Learning difficulties, lower educational achievement, or difficulties communicating
• Acts cruelly toward people or animals
• Criminal behavior

Family/home environment

• Substance abuse in the home environment
• Domestic violence in the home (whether current or past, witnessed or experienced)
• Past or present homelessness or inadequate housing
• Joblessness, unemployment, or other problems with money
• Family members under a lot of stress
• Loss, death, or suicide of a family or community member (see Chapter D-22: Grief )
• Lacking support from family, friends, or community
• Family member with mental or physical illness
• Caregivers issues:
  • Too busy to spend time with the child
  • Limited supervision, structure, routines, consistency, and predictability
  • Different caregivers who have different rules or expectations of the child’s behavior
  • Caregiver who has been abused as a child
  • Caregiver who does not stand up to protect a child or vulnerable adult from abuse
  • Caregiver who is unaware or is unwilling to identify what happened to the child or vulnerable adult as abuse

Assessing Safety and Security

• Do you have enough food at home?
• Do you feel safe at home?
• Do you feel safe in the community?
• What is your housing situation like?

Relationships

• Whom do you trust?
• How well do your family members get along?
• What is your relationship with your caregivers and family members like?

Behavioral Health

• Have things been more stressful than normal lately?
• How is your sleep?
• How is your appetite?
• How is your mood?
• Do you ever think about suicide? See Chapter D-5: Suicidal Thoughts and Plans.
• Have you ever cut yourself or harmed yourself in any way?
• Are you on any prescription medications?
• Do you use drugs or alcohol?

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

• Healthy exercise.
• Engaging in culturally relevant activities.
• Participating in safe community events.
• Maintaining a healthy diet.

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.