Tier 3 – Specialist knowledge

Knowledge

In addition to Tier 1 & Tier 2 knowledge, you need to know: 

• many victims and survivors will have experienced a range of adverse childhood experiences and multiple forms of trauma
• victims and survivors may present with signs or indicators of complex trauma
• victims and survivors with presentations of complex trauma may be engaged with multiple services to provide an integrated or holistic response
• some children and young people who have experienced child sexual abuse may also display concerning or harmful sexual behaviours.

Skills

In addition to Tier 1 & Tier 2 skills, you can: 

• draw on your knowledge about the dynamics of abuse in different contexts when working with victims and survivors
• work successfully with victims and survivors with complex trauma and adapt your usual practice to accommodate complex needs
• recognise the need for collaboration between service providers when working with complex cases and facilitate coordination of care
• consult clinical or therapeutic guidelines for work with children and young people who have experienced child sexual abuse and who have also displayed concerning or harmful sexual behaviours.

Did you know?

Australian Child Maltreatment Study 

The Australian Child Maltreatment Study provides the first nationally representative rates of all 5 types of child maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence) and their associated outcomes in Australia. It is important that you recognise that there may be a co-occurrence of other child maltreatment issues with child sexual abuse, which may influence the way in which you approach your work.

Changing terminology 

The term sibling sexual abuse is commonly used in practice and literature; however, a different term, ‘children and young people who have displayed harmful sexual behaviours towards a sibling’, is now recommended by the National Office for Child Safety, academics and practitioners who specialise in responding to children and young people who have displayed harmful sexual behaviours. If you are interested in further understanding this change in terminology, please refer to the National Centre for Action on Child Sexual Abuse’s Understanding harmful sexual behaviours resource.

Harmful sexual behaviours 

An Australian study published by the Australian National Research Organisation for Women’s Safety (ANROWS) in 2020 explored experiences of children and young people who have displayed harmful sexual behaviours towards a sibling and the effects on families.

Knowledge

In addition to Tier 1 & Tier 2 knowledge, you need to know: 

• victims and survivors may present with complex needs and/or complex trauma requiring a dynamic and collaborative approach
• a victim or survivor’s responses to the trauma of child sexual abuse can be affected by:
  • life experience
  • accessibility of support, justice and healing opportunities
  • coping and life skills
  • responses of family, kin, supporters and community
• there is a neurobiological basis to an individual’s response to the traumatic impact of child sexual abuse
• there may be value in trauma processing strategies for some victims and survivors; however, others may prefer different healing strategies
• the importance of framing dissociation, avoidance and self-medication as coping strategies in the context of trauma
• some victims and survivors from Aboriginal and Torres Strait Islander communities who have experienced intergenerational trauma and child sexual abuse will prefer to engage with Aboriginal and Torres Strait Islander workers and organisations, while others will not – providing service choice, where possible, is important
• children, young people and adults who are victims and survivors may still feel unsafe and live in unsafe environments even if the abuse has stopped
• many victims and survivors may seek free services due to the cost of private counselling and psychological support services.

Skills

In addition to Tier 1 & Tier 2 skills, you can: 

• reflect on your practice and generate new ideas and strategies for managing complex needs and/ or complex trauma
• collaborate with the victim or survivor to identify and reflect on their strengths and skills and how these might be used to cope with current difficulties
• provide information to victims and survivors about protective functions of trauma reactions
• recognise when a victim or survivor is responding with dissociation or avoidance or is self-medicating, and intervene effectively
• provide accessible information about the neurobiology of trauma to empower victims and survivors to better understand their trauma responses
• recognise the role and value of different interventions in overcoming the impacts of trauma, and implement the most appropriate option in collaboration with the victim or survivor
• ensure any information provided is age-appropriate, and sensitive to a diversity of health literacy and cultural contexts
• establish partnerships with specialist services, such as those for people with disability and LGBTQIA+ people, for referral and to provide specialist consultation to you as needed
• with the consent of the victim or survivor and/or their parents and caregivers, advocate in educational settings for understanding behaviours to keep children and young people affected by trauma engaged in education
• recognise and manage ongoing risk in relation to all forms of violence, abuse and neglect in collaboration with other services.

What do victims are survivors tell us?

Learning from victims and survivors about help-seeking 

Michael Salter and Jan Breckenridge's research paper on women, trauma and substance abuse focuses on adult victims and survivors discussing their experiences of seeking help from alcohol and other drug and mental health services.

Resource

Trauma 

The Blue Knot Foundation has Practice Guidelines for Identifying and Treating Complex Trauma-Related Dissociation.

Living Well resources for men 

Living Well is an Australian service and resource that provides information, encouragement and support to men who have experienced child sexual abuse or sexual assault in adulthood. Their resource on dealing with the effects of childhood sexual abuse provides strategies for when existing coping mechanisms become unhelpful.

Inclusive practice with LGBTQIA+ communities 

The Victorian Department of Health has produced a suite of ‘Community health pride’ resources, including the LGBTQIA+ inclusive practice toolkit.

Knowledge

In addition to Tier 1 & Tier 2 knowledge, you need to know: 

• victims and survivors can be triggered and become hyper (over) or hypo (under) aroused by overwhelming emotions, meaning they have gone beyond their ‘window of tolerance’
• how to develop and implement tailored strategies to support victims and survivors stay within their window of tolerance
• the importance of providing safety and building trust, giving choice and control, and engaging with the victim and survivor to reduce the likelihood of triggers and exceeding their window of tolerance.

Skills

In addition to Tier 1 & Tier 2 skills, you can: 

• recognise where a person has exceeded their window of tolerance and intervene where appropriate and within your role
• employ a range of grounding strategies and individually tailored techniques to allow the victim and survivor to return to their window of tolerance
• anticipate possible triggers for victims and survivors within the service delivery environment and collaboratively develop a plan to address these
• ensure that systems and procedures in your service are sensitive to trauma triggers
• support victims and survivors of a range of ages and developmental stages to develop skills in self-soothing or grounding techniques.

Resource

Window of tolerance 

The Window of Tolerance video by Laurel House, a sexual assault service in Tasmania, provides helpful information for therapists and other health professionals about the ‘window of tolerance’.

The US National Institute for the Clinical Application of Behavioural Medicine (NICABM) has a useful infographic on trauma to help victims and survivors understand their window of tolerance.

Knowledge

In addition to Tier 1 & Tier 2 knowledge, you need to know: 

• it is important to adopt trauma-informed policies and procedures, particularly managing engagement with victims and survivors, follow-up, wait lists and missed appointments
• some victims and survivors and their supporters may take time to decide whether they can trust your service and how to engage
• it is important to complete a thorough psycho-social assessment before commencing any specific therapeutic strategies such as trauma processing
• the importance of ongoing reflection, review and consideration of new evidence to inform your responses and to ensure your own wellbeing.

Skills

In addition to Tier 1 & Tier 2 skills, you can: 

• identify and select evidence-based trauma-focused therapies and support options most likely to be effective for the victim or survivor you are working with
• with the support of your organisation, take responsibility for your professional development to ensure current evidence, including cultural knowledge and practices, underpins your work
• use relevant risk screening tools, and manage risk related to child sexual abuse and other risks such as domestic and family violence and suicidality
• recognise when trauma reactions are compromising the safety of the victim or survivor and/or others
• respond as needed to address risks and develop safety plans in collaboration with the victim or survivor, and where appropriate, their family, kin and supporters
• recognise where further assessment of the impact of trauma on a child’s development is required and make appropriate referrals.

Did you know?

The work of Dr Judith Herman and Dr Bessel Van Der Kolk 

Any therapeutic engagement in the area of child sexual abuse and trauma requires an understanding of the key contributions of: 

• Dr Judith Lewis Herman in her books Trauma and Recovery (1992) and Truth and Repair (2023)
• Dr Bessel Van Der Kolk in his book The Body Keeps the Score (2014). 

Watch these authors speak about their recent work.

Resource

Standards of Practice 

NASASV Standards of Practice Manual for Services Against Sexual Violence (3rd edition) – All standards.

Knowledge

In addition to Tier 1 & Tier 2 knowledge, you need to know: 

• some victims and survivors may not choose individualised face-to-face therapeutic interventions and may instead find other support more helpful, including:
  • peer-based support
  • art therapy
  • creativity and play (especially for children and young people)
  • culturally responsive healing that strengthens cultural connectedness and social and emotional wellbeing
  • spiritual and faith-based approaches
  • peer and lived experience connections
• a connected and engaged working or therapeutic alliance is key to providing any response to trauma
• the importance of supporting victims and survivors to develop emotional regulation
• making sense of trauma is an ongoing process in the recovery journey
• the importance of accessing professional supervision for your professional development.

Skills

In addition to Tier 1 & Tier 2 skills, you can: 

• ensure your practice is guided by the victim or survivor about what they believe best addresses their needs
• discuss different approaches and options for addressing the impact of trauma in counselling
• build a trauma-informed working or therapeutic alliance
• involve family members, kin and supporters in discussions and decisions about trauma-processing therapy where appropriate and with the victim and survivor’s consent – this is particularly relevant when working with children and young people
• check in with victims and survivors about whether therapeutic approaches are meeting their needs and remain open to adapting your practice or referring on where appropriate
• assist victims and survivors and, where relevant, their family, kin and supporters, to recognise when they may need to seek additional support at later stages in their recovery.

Did you know?

Therapeutic alliance

Jill Levinson's research article explores how trauma-informed responses can strengthen the therapeutic alliance.

Practice tip

Emotional regulation skills 

• For children: Emotional dysregulation in children who have experienced adversity
• For young people and adults: Bessel van der Kolk presents Emotional systems (YouTube video)

Peer support 

Many victims and survivors find peer-support to be very effective because it offers a level of acceptance, understanding and validation to people who have had similar experiences. It is more often used by young people and adults. Some sexual assault services may offer groupwork programs that provide support for peers. You might like to visit the following peer-support websites which can also be used as referrals: 

• Blue Knot Foundation
• Bravehearts
• MensLine Australia
• The Healing Foundation
• SAMSN
• Kids Helpline

Resource

Complex trauma 

“A deep wound under my heart”: Constructions of complex trauma and implications for women’s wellbeing and safety from violence 
– Research report by Salter et al. (2020)

Trauma and attention-deficit hyperactivity disorder 

This resource answers common questions around attention-deficit hyperactivity disorder and the assessment of trauma.