ACSSA Aware

No. 24, 2010

Published by the Australian Institute of Family Studies
ISSN 1448-8140 (Print); ISSN 1448-8167 (Online)
ACSSA Coordinator: Antonia Quadara

Publications from the Australian Centre for the Study of Sexual Assault (ACSSA) are available from the Australian Institute of Family Studies (AIFS). If you would like to receive future publications as they are released please register your details for the ACSSA mailing list.

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Contents

In this issue

Welcome to Aware 24, the newsletter for the Australian Centre for the Study of Sexual Assault. In this issue we are very pleased to publish two discussions built upon a wide range of contributions.

The first discussion has a focus on dementia and elderly survivors of childhood sexual abuse. It includes an interview with Adelle Williams), a specialist aged care trainer, and a conversation between Jill Duncan, from CASA House, and Rhonda Pryor, an aged care practitioner. Rob Gordon, a clinical psychologist with 30 years experience, provides a crucial background about the nature of trauma related to childhood sexual assault, and the relationship trajectory of ageing, memory and remembered trauma.

The second discussion is about public education media campaigns, with a focus on the recent (and controversial) "Father of the Bride" campaign initiated by the Adult Survivors of Child Abuse (ASCA). Cathy Kezelman (ASCA) provides a background to the campaign, and Jane Caro (a media commentator and advertising expert) reflects on her own media experience and reactions to the ASCA campaign. Leah Bromfield (Manager of the National Child Protection Clearinghouse) and Antonia Quadara (ACSSA) look at the broader field of media campaigns relating to sexual assault.

In Brief provides a summary of a number of current publications relevant to the sexual assault sector and Literature Highlights showcases a range of publications with a focus on surviving sexual assault trauma and dementia and on prevention campaigns and media.

All of ACSSA's publications are available online. Visit our website at <www.aifs.gov.au/acssa>, where you can also browse our Promising Practice Database, peruse specialised bibliographies, look for upcoming events, or submit your research queries.

ACSSA welcomes contributions to newsletters from workers and researchers in the sexual assault field. We can assist with the development of your idea for an article to publish in ACSSA Aware; please get in touch with a member of the ACSSA team if you feel that you have something to contribute.

Antonia Quadara
ACSSA Co-ordinator

IN BRIEF

National

Secondary Students and Sexual Health 2008: Results of the 4th National Survey of Australian Secondary Students, HIV/AIDS and Sexual Health

Smith, A., Agius, P., Mitchell, A., Barrett, C., & Pitts, M. (2009). (Monograph Series No. 70). Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University

Summary by Dr Rachel King

Secondary Students and Sexual Health 2008 reports on the responses of nearly 3,000 Year 10 and Year 12 students enrolled in over 100 secondary schools from the government, catholic, and independent school systems in every jurisdiction in Australia. The 2008 report is the fourth of its kind that has been conducted in Australia, and was originally instigated to investigate HIV-related knowledge, attitudes and practice. The reports are published in approximately 5-year intervals (1992-1997-2002-2008).

The focus of the survey has shifted slightly over time to reflect issues pertinent to relevant generations (e.g., the current survey addresses the introduction of mass vaccination campaigns against HPV) however, the 2008 survey continued with previous themes such as those related to young people's sexual behaviour and condom use. Of particular interest to those in the sexual assault field are the components of the survey that address the nexus between alcohol and drug use and unwanted sexual activity.

Some of the key findings of the report include:

The report explains the increase in unwanted sex and the decline in more positive feelings for young women after sex from the 2002 survey by stating the correlation between the marked increase in participants reporting that they had unwanted sex at some time, and that the role of alcohol in unwanted sex is becoming increasingly prominent.

These gender differences are explored by examining feelings and satisfaction in more detail. The report found students generally expressed positive feelings after their last sexual encounter, with more than one-third of sexually active students reporting they felt "extremely" good, happy, fantastic, or loved after their last sexual encounter. Similarly, students were less likely to endorse the items conveying negative feelings after their last sexual encounter. A relatively small proportion of students reported feeling "extremely" used, regretful, worried, upset, or guilty the last time they had sex. However, young men were more likely to view sex in a positive light than young women. More young men reported feeling "not at all upset" (85%) after their last sexual encounter than did young women (76%). The report also found female students were less likely than male students to report feeling "extremely" happy, good, fantastic, and loved. However these differences were not statistically significant. These findings are important for understanding women's agency within sexual relationships, and the apparent imbalance between young men and women's abilities to negotiate free agreement to wanted sex.

While the response rate to this survey was lower compared to previous iterations, and Year 12 students were especially underrepresented, significant corrections were enacted by the researchers to mimimise the impact that these, and other sample and survey limits, would have on the analysis of the data. The survey comprises quantitative questions, and as such, the report focuses on statistical findings.

Qualitative data would be useful for exploring further nuances of students' experiences, especially those related to unwanted sex. The report does not offer implications for prevention education or government policy direction. However, the data collected in previous surveys has been widely used throughout Australia to inform educational policy and practice in the sexual health areas and by health departments to plan interventions for young people.

The authors' final message is of importance for the sexual health sector, they state:

It may now be time to call a halt to the expansion of items that fall under the rubric of secondary students' sexual health and instead focus on what it means to live a good sexual life. (p. 62)

This final assertion does provide important meaning for the sexual health sector, as increasingly, politicians, researchers, and practitioners emphasise the importance of focusing on a positive standard of sexual life, ethics and behaviour.

A Rollercoaster Ride. Victims of Sexual Assault: Their Experiences with and Views about the Criminal Justice Process in the ACT 2009

ACT Government

Summary by Dr Rachel King

A Rollercoaster Ride presents data from two studies of adults who had experienced sexual assault and had reported the incident to the police in the ACT. The impetus for this research was to examine in depth the expectations, experiences, and views of adult victim/survivors of sexual assault. The report aimed to ascertain participants' reflections on issues of control, preference, and choice in criminal justice proceedings.

The study used both qualitative interviews and a computer assisted personal interview (which was designed for a larger national research project). The qualitative interviews examined the views and experiences of victims of sexual violence, utilising the following themes:

The quantitative survey examined additional issues including how procedural and outcome factors interact with variables such as the nature of the offence and the relationship between the victim and offender, and how they shape victims' recovery from victimisation and their use of victim support services.

Key findings included:

Victim/survivors valued highly the principles of procedural fairness, including honesty, absence of bias, fair and just decision-making, and inclusion. How individuals actually experienced these principles and values in the ACT was somewhat mixed. Most victim/survivors found police, prosecutors, and victim liaison staff to be supportive and as such did not withdraw their complaint. The judiciary was also experienced as supportive and respectful, as was the victim liaison staff. Defence lawyers however, were seen to make the court process difficult and humiliating.

While participants outlined positive elements of their experiences with most criminal justice personnel, a range of specific elements were noted to be unhelpful and discouraging. In particular:

The report also illustrated victim/survivors felt the reporting decision was correct for them, and they experienced a sense of responsibility in apprehending the perpetrator before they could reoffend. Importantly, victim/survivors felt their input and involvement should be considered in the criminal justice system, but they did not want the responsibility of any decision-making.

The research methodology does present some limitations regarding the generalisation of the findings. The qualitative component sample was seven individuals; one male and six female, and the quantitative sample was four (no demographic details were provided). The sample was also atypical, as the majority of participants not only had the offence committed against them charged and prosecuted, but also the majority had their case result in a plea or a finding of guilt. The report does acknowledge these limitations; results should be considered for both components with this in mind.

While the report does not offer recommendations for improved criminal justice responses, it is clear from the ACT report that victim/survivors of sexual assault do want their cases to be heard via the criminal justice system. Ultimately, they are seeking acknowledgement, vindication, and protection of themselves and the community in seeking recourse via the criminal justice system. This has important implications for future considerations of how to most effectively respond to sexual assault. Victim/survivors value the opportunity for their cases to be heard via the criminal justice system. As such, focus should be on how to ease the process and reduce the negative elements of victim/survivors experiences.

International

Fortieth Pacific Islands Forum

Final Communique of 40th Pacific Islands Forum, Cairns. (2009). Pacific Islands Forum Secretariat

The 40th Pacific Islands Forum, held in Cairns in 2007, addressed various issues, including those related to sexual and gender-based violence. At the forum, Pacific Islander leaders reaffirmed high-level support to raise awareness of sexual and gender-based violence and its impact on the Pacific, and to establish it firmly within political agendas. They also acknowledged the prevalence and risks associated with sexual and gender-based violence, and supported efforts at the local, national and regional levels to address it. This included increasing Pacific engagement in global prevention initiatives. The forum leaders stated their commitment to eradicating sexual and gender-based violence, and legal and justice equality for all individuals

Available at: <www.forumsec.org.fj/pages.cfm/newsroom/press-statements/2009/final-communique-of-40th-pacific-islands-forum-cairns.html>.

DISCUSSION FOCUS

Ageing, dementia and adult survivors of childhood sexual assault

In 2008, Adelle Williams approached ACSSA to discuss the training model she was developing, Trauma "Revisited" and Ageing - The Forgotten Australians*, which she hoped would provide skills for carers working with people with dementia who were re-experiencing the trauma of childhood sexual assault. We were immediately struck by the significance of this issue. Australia has a growing ageing population, which is paralleled by an increasing number of dementia diagnoses.

Our investigations into research concerning ageing, dementia and childhood sexual assault suggested there is a substantial research gap. However, we also found there was significant interest to learn more about the convergence of these issues, with rapid and enthusiastic responses, particularly from Alzheimer's Australia and their networks, and CASA House. Consequently, ACSSA has drawn together different perspectives - clinical, aged care, and sexual assault services - to synthesise these discrete knowledge bases to begin addressing the research gap.

The following "discussion" about the convergence of ageing, caring and the survival of childhood sexual assault begins with a contribution from Rob Gordon, a clinical psychologist with a private psychotherapy practice who has treated a wide range of trauma over the last 30 years. Rob has been a consultant to the Victorian State Emergency Recovery Plan for 20 years and is also a consultant to the Red Cross. Rob's contribution, The Passage of Trauma Through Life, provides crucial background information about the particular nature of trauma related to sexual assault, and childhood sexual assault specifically. He outlines the continual survival in its relationship to the trajectory of ageing, memory and remembered trauma.

Rob's piece supplies an important framework for the conversations that follow; his work is an application of trauma theory to dementia. Adelle Williams discusses how she became aware of the particular issue of dementia and the re-experiencing of childhood sexual assault. She also talks about the training model she has developed to help carers caring for people with dementia who display the signs of retraumatising memories of sexual assault.

We have also included a conversation between Jill Duncan from CASA House in Melbourne and Rhonda Pryor. Rhonda has been working as a manager of aged care services in Victoria for 12 years. In this conversation Rhonda reflects on her experiences caring for elderly patients who disclose memories of childhood sexual assault.

* from 2011 the program Trauma "Revisited" and Ageing - The Forgotten Australians is known as Caring Through Connections.

The passage of trauma through life

Rob Gordon

The term "trauma" is so loosely used now, that it's meaning has become confused. The word comes from the Greek meaning "wound", and in medicine indicates externally caused bodily damage. Psychological trauma involves an experience of such intensity that it damages underlying assumptions or expectation about the world or the self. When the trauma is sexual, it may damage the sense of self and the relationship of the person to their body and to other people. When traumatic experiences occur in early childhood, they undermine the development of the very sense of self and the basis for future developmental stages.

It is often considered that the answer to traumatic injury is to "work it through" and "resolve" it. It is certainly necessary for the affected person to gain control of the fear, distress, and confusion that accompany the intense emotion and confuse the present with the past. Intrusive and distressing memories must be reduced in intensity so they can be linked to other past experiences, and turned from disconnected fragments into episodes of personal history. Then they can have a relationship of meaning, cause and effect, value, and ethical clarity for the person.

But alongside this, adequate treatment must help the person to confront the impact of the experiences and reduce their intensity so they do not have to avoid and block them out or shut down anything that might evoke them. Then restrictions on the lives of people who have suffered traumatic events can be lifted and they can begin to reclaim their lives.

When these are achieved, the person can say they have the memory of a past event which they have survived and can begin to create their lives as an expression of who they want to be. However, this is a simplification when the trauma is of a sexual nature and also when it occurs in early life.

Sexual trauma may not always involve clear threat, particularly in the case of incest. There is confusion when an adult carer abuses the child. Since the child has no independent reference point from which to judge the event, they cannot arrive at their own point of view, or understand the event as bad and that they should seek protection. A frequent consequence is that young children are unable to avoid further occasions of abuse and the whole experience becomes bound up with the developing sense of self - with damaging consequences. In this case the wound of the trauma is to the sense of self.

One of the deepest damages is that the abuser of young children is intent on using the child for their own satisfaction, without regard to the needs or experience of the child. The child feels they are not acknowledged as another person - they are "depersonalised", and instead made into an object of satisfaction or of consumption.

The wound here is to the essence of social relationships - that when one person interacts with another, both inescapably recognise and are influenced by the fact that the other is having an experience of the interaction. Other people matter and we all hold each other in our minds as we interact. This link is shattered and the child is left wondering if anyone knows them; they feel an aloneness that makes life hard to bear. It has to be shut out.

Often sexual trauma is not treated soon after it has occurred at any stage of life. The longer it goes before it can be addressed in a safe and supportive relationship, the more it will be built into the developing personality. It cannot remain as a separate thing, it must influence everything, because it is part of the nature of living things that they incorporate what happens to them into themselves. Education is based on the idea that children are influenced by what happens to them, so we try to give them good experiences that are incorporated and influence the development of their personality. Therefore, trauma is like bad education.

If the child does not receive help at that stage, the process of development proceeds, not only with the possibility of repeated traumatic episodes, but with a wounded self as the foundation of the future stages. Instead of growing into a greater confidence and valuing themselves, the trauma continues to exert and influence, like building a road over a piece of boggy ground - it keeps sinking.

These are some of the ways sexual trauma in early life can lead to damaging consequences for those exposed to it. However, the resilience of human nature ensures the child, the later adolescent, and the adult who has been abused, creates a life. They confront and remodel themselves as best they can, to avoid or shut down disturbing experiences and divert themselves to find sources of enjoyment or self-expression.

To an outward gaze, the child may grow up and achieve much, but wounds are ignored or avoided. It is to be expected that as new experiences and stages of development open up, the consequences of the trauma may come to the fore in unexpected ways.

Personal development through life is a combination of, on one hand, the unfolding of new capacities through growth and maturation, and on the other hand, opportunities to express and shape or enhance these capacities through activity. A capacity has to be expressed to become part of the personality, and this has to be repeated at each stage. The sense of self, emotional life, capacity for understanding, experience of the body, and relationship to other people all has to be reworked again and again.

There are important transition points in development such as around age 9, puberty, middle and late adolescence, early, middle, and late adulthood; and there are the important landmarks of becoming independent, becoming sexually active, partnering, having children, having grandchildren, death of parents and so forth. At each of these stages, if development has done its job, relationships, body, sexuality, emotions, and past experience need to take on a new meaning and be rearranged within the personality. The wounds are also part of this process and continue to exert an influence throughout life.

The older a person gets, the intensity of emotions changes, the body is not so urgent and they have a more secure sense of self. These features may then unexpectedly bring to the fore past wounds. Another trauma, loss, or crisis may bring the earlier event to mind. But it may not involve an event with any outer resemblance to the sexual trauma. It may come up because the person is placed in circumstances that have the same emotional character. For example, feelings of being alone and having no one to turn to; being misunderstood and isolated; being devalued; or unable to see how the future will turn out. All or any of these may plunge the person back into the same mood as the earlier time; then it is as though the sense of personal history collapses, they lose their footing in the present, and feel immersed in the past.

This can be a dangerous and distressing time, and there is no guarantee the person will understand what is happening, or the source of their feelings. They need above all to regain their footing in the present and take hold once again all their achievements; then from there, within a safe emotional and social environment begin to heal the wounds.

People may also have a deeply intuitive sense of what is possible for them, and often allow themselves to remember what has happened, or feel they can confront the wounds when their life circumstances make them feel it is safe to do so. Safety may come from having achieved a greater sense of maturity and security, from a more secure relationship, or from having proven their capacity in other fields.

Then memories may erupt in what seems a totally unexpected way; or memories that have been there all the time, are suddenly activated with intense emotion and can no longer be put aside. Often this shows a need to heal that which has been limiting their development, and is a constructive crisis, however, it requires sensitive care and support for the healing opportunity to bear fruit.

It is therefore to be expected that trauma involves wounds or damage to all sorts of aspects of the person. The effects are as specific and defined as the physical injuries sustained in an accident. The fact that we are not used to tracing them with equivalent detail is because we tend to focus most on the emotional consequences of the psychological injuries. But the wounds or effects of serious trauma remain throughout life, and even if they are cared for and treated when they first occur, it is not possible for them ever to be completely over and done with. They must have a meaning which changes as the parts that are wounded change, and as the person as a whole matures.

Living with trauma is therefore a life-long process as it is reworked at each phase. But this does not mean constant vulnerability; it is like all aspects of growth. They build on what is already there - where there are wounds, there are limitations, but then all limitations can become opportunities for unexpected growth. Simplistic notions of trauma as a purely emotional experience, which can be fixed once and for all, are misleading for most people.

If the return of these experiences in later ages is unexpected - even in old age when things were meant to become more peaceful as indicated by the term "retirement" - it can be frightening and confusing. If the events have not been worked with at all then the whole experience opens up like a raw wound.

What is important is that traumatic experiences are made safe to become part of personal growth. At each stage of development, the first task of the therapist must be to ensure the person can resume their development and that the wounds they have sustained do not disrupt their growth. Part of this understanding is to consider how much the experience can be resolved at the particular point of life they are at, and how much will it really require the advantage of greater maturity to do it. The goal may be to enable the trauma to be tolerated as something expected to return, but without the earlier intensity and pain. Then it can lead to growth and further development. Because it is true that those who have suffered and healed have also felt a depth to their being which others may not ever be aware of. The lifelong relationship to the trauma is then both something for sadness and regret, but also something for developing a capacity for acceptance of a reality that many do not find.

Often the last stage of life is the opportunity to put things into perspective and this can only be done by remembering them. Then it is important to be able to talk about them.

Rob Gordon PhD is a clinical psychologist with a private psychotherapy practice who has treated a wide range of trauma over the last 30 years. He has been a consultant to the Victorian State Emergency Recovery Plan for 20 years and is also a consultant to the Red Cross. He provides supervision for agencies working with clients affected by various forms of trauma, sexual abuse, personality disorder and suicide.

Dementia and survivors of childhood sexual abuse: An interview with Adelle Williams, Communication Change Observation Respect and Dignity Aged Care Training Specialist

Haley Clark and Kirsty Duncanson

As a specialist in aged care training Adelle Williams has been developing a model for caring for people with dementia who are also survivors of childhood sexual abuse. Adelle talked to ACSSA about the issue of dementia care and the recognition of triggered traumatic memories of childhood sexual assault. She also talked about the model she is developing to care more effectively for people with dementia who are experiencing traumatic memories of childhood sexual assault.

ACSSA: Can you tell me about dementia and its connection to child sexual abuse?

Adelle: Australians are living longer, and 25% of people over 85 years will get some form of dementia. In Australia, 1,000 people are diagnosed with dementia per week, and this is expected to double in the next 20 years (Alzheimer's Australia, 2008). When dementia progresses, recent memories peel away (like the outer skins of an onion). The person becomes "feelings-based" and past memories are "triggered" by people, smells, noises and other stimuli. Unfortunately past trauma can be "relived" when memories or feelings are triggered. As approximately one in four girls and one in six boys have been sexually abused, there is good reason to suggest that this trauma can be triggered and repeatedly relived by the individual. This is especially so with dementia as it progresses and the armour developed to cope with trauma breaks down. Further to this, a recent study has shown that people who suffered trauma in their early life are more susceptible to a dementia in later years (Charles et al., 2006).

When these memories or feelings of previous trauma are triggered, the person exhibits "challenging behaviours". But the question has to be: to whom are these behaviours challenging? To the person reliving the trauma, the behaviours are appropriate to his or her reality. With sensitive care and correct responses, the associated distress will be relieved and in some cases eliminated for those people affected.

ACSSA: How did you become aware of this issue?

Adelle: The idea of dementia having a significant link with child sexual abuse is a relatively unexplored concept. During my 28 years working with elderly people, this idea has become more of a probability and less of an unsubstantiated belief. Trauma "Revisited" and Ageing - The Forgotten Australians is a specialised program I developed to educate and train staff working with elderly people to more effectively address behavioural issues in people with dementia, due to early life trauma. It is, of course, very important to recognise that trauma may be caused by other factors than child sexual abuse, such as adoption, the Stolen Generation, and events during World War II.

Trauma caused by childhood sexual abuse is not necessarily more distressing than trauma caused by other events. I have simply gone into greater depth with child sexual abuse in an attempt to remove the secrecy and stigma related to this topic, and to assist in the improvement in the quality of care for elderly people.

ACSSA: What is dementia, and what does it mean for a person to become "feelings based"?

Adelle: Dementia is the term used to describe symptoms of a collection of diseases and illnesses such as: Alzheimer's disease, vascular dementia, frontal temporal lobar degeneration (FTLD) and dementia with lewy bodies, among others (alzheimers.org.au). Dementia is not an illness, but rather a syndrome, or set of symptoms that result from organic damage to the brain due to certain diseases or conditions. Dementia presents with a number of the following:

When dementia is present, it is the result of damage or the death of neurons in the brain. This affects the transfer of messages through the chemical exchange called synapses. Even though we can't see the damage of these neurons and synapses, they have very real consequences.

Dementia is progressive and there are a number of stages that are often described as "early," "moderate", and "severe". These stages are not fixed, which makes it very difficult for the individual living with the dementia and for their family. Due to the nature of dementia, grief and loss go hand-in-hand as the person moves from early stage dementia to moderate and back again. With the changes, the stages of grief are often experienced and re-experienced.

Memory loss plays a huge part in this degenerative process, leading to an individual possibly reliving past trauma. Gideon Caplan explained this well on the ABC Television program Compass:

Well, what you see in many people with dementia is like peeling an onion, in the sense that the layers of memory come off with the most recently put on layers coming off first. And then going down through the past. And now that those other layers are coming off, or now that they have less ... ability mentally to contain it, that genie comes out of the box and the reactions to that trauma now become much more present. (ABC Television, 2006)

People often place huge amounts of energy into covering up their trauma in order to live a "normal" life, at least on the surface, so that their "secret" is not discovered. Dementia, purely by the nature of the syndrome removes the amour that the people have built around themselves to keep their secret safe. Dementia exposes the person, leaving them vulnerable and scared to relive the memories and or feelings associated with the trauma.

The further a dementia progresses, the more "feelings" based the individual becomes, causing past trauma to be relived when memories are triggered. A person may intuitively pick up on stress from his or her environment and the people in it, and react accordingly with "inappropriate" behaviour. To complicate matters, verbal communication often becomes difficult for those with dementia. This is made even more difficult as the person with dementia often lives in his or her own reality, which is often not easily understood by others.

ACSSA: What are the signs that a person is re-experiencing the trauma of childhood sexual abuse?

Adelle: Children who have been sexually abused place enormous amounts of effort into surviving, in the family, at school, with relationships, and in keeping "the secret". As adulthood approaches many issues arise that they may be ill equipped to deal with. Guilt, fear, and threats reinforced by a simple look can keep the adult as controlled as they were as a child, even though the abuse occurred many years ago. Coping strategies and amour are developed for protection, but the effects of abuse remain and can be a focus point in future decision-making. Dementia means that a lifetime of coping skills may be peeled away.

Those with dementia can exhibit behavioural changes that may suggest they have been sexually abused as a child. They include but are not limited to:

People with dementia who have been sexually abused can become very difficult to manage for family and health workers. Public outings may be particularly difficult, and people have to become vigilant in the protection of the vulnerable family member as well as themselves and others. Personal hygiene is particularly challenging and patients can became less cooperative. Carers may withdraw affection, and verbal communication can become strained and physical interaction withdrawn.

A terrible result of this can be that elderly survivors often become isolated, and verbal and physical aggression escalates.

ACSSA: What kind of strategies do you propose to help relieve the distress of re-experienced trauma?

Adelle: Positive outcomes are possible by recognising particular behaviours, isolating the triggers, and avoiding them or finding an alternative to increase the quality of life for the elderly person. With skilful observation, education, and appropriate training, the relationship between the staff and the individual becomes rewarding for both. This then offers the survivor of child sexual abuse the opportunity to heal.

Strategies need to be developed to assist people with dementia while maintaining respect. For example:

ACSSA: Can you tell us about the program that you have developed?

Adelle: Trauma "Revisited" and Ageing - The Forgotten Australians was developed for the one in four females and one in six males affected by childhood sexual abuse, especially those who suffer dementia, the people who care for them professionally, and the family and friends of the people who know and love them. Childhood sexual abuse touches us all whether we know it or not. An elderly person who has experienced this trauma has caring people around them assisting them with their daily life. These carers may trigger, quite unknowingly and on a frighteningly regular basis, the sexual abuse that the person suffered as a child. Now add dementia and they may relive that trauma over and over again.

The program I have developed is designed to offer practical training to educate staff in recognising the signs and behaviours of possible child sexual abuse, for elderly people with dementia. Appropriately applied it will relieve, and in some cases eliminate, the associated distress.

Communication must be handled with extreme sensitivity and professionalism. Confidentiality must be maintained. Family and friends may not be open to addressing the issue at all. While it is important for staff to obtain as much insight as to the possible origin of the "challenging behaviour" people exhibit and the distress that it causes, limiting the distress is primarily the focus, regardless of the origin. When we consider the effort the person has put into "keeping their secret", the repercussions of sharing theories from staff observations may be devastating to family. Moreover it is very important to note that a person with dementia may display possible signs of early trauma including that of child sexual abuse without a trauma such as this having occurred at all.

Trauma "Revisited" and Ageing - The Forgotten Australians is a multi-facetted workshop-training program for experienced care staff that lasts between 1-3 days, with a brief follow-up conducted approximately one week later. Within this model, a number of staff would attend the longer training model in order to establish a core staff group with the specific capacities for actively working with the residents displaying the challenging behaviour associated with the revisited trauma of childhood sexual assault. The model is a person-centred care approach, putting the person at the centre of the program; this ensures the program fits the individual person.

It is expected that participants completing the shorter, one-day training program would end with an ability to identify specific behaviours, which may indicate early trauma being revisited by a patient. They would then be able to filter this information to a core group of staff that had completed the further 1-2 day training program. The aim of the longer course is to provide participants with alternative care methods to help reduce or eliminate the challenging behaviours, including resident distress, and to inform all care staff via staff care who would then practice these alternative methods.

References

Alzheimer's Australia. (2008). Dementia facts & statistics. Alzheimer's Australia: Australia

Charles, E., Bauby-Serieys, V., Thomas, P., & Clément, J.P. (2006). Links between life events, traumatism and dementia: An open study including 565 patients with dementia. Encephale, 32, (5 Pt. 1), 746-52.

ABC Television. (2006, October 22). Compass: Plagued by memories. Retrieved from: <http://www.abc.net.au/compass/s1748774.htm>

Haley Clark is a Senior Research Officer at the Australian Centre for the Study of Sexual Assault. At the time of writing Kirsty Duncanson was a Research Officer at the Australian Centre for the Study of Sexual Assault.

A short conversation about elderly survivors of sexual assault and dementia

Jill Duncan and Rhonda Pryor

Jill Duncan of CASA House in Melbourne talked to Rhonda Pryor, who has been working as a manager of aged care services in Victoria for 12 years. Rhonda reflects on her experiences caring for elderly patients who disclose memories of childhood sexual assault.

Jill: In your role managing aged care services over many years, have you seen behaviour in the elderly that led you to draw connections between apparent dementia and possible re-experiencing of child sexual assault?

Rhonda: Dementia encompasses a range of conditions that impact on the cognitive functioning of the brain. The dementias I have most experience of observing are Alzheimer's and vascular. I do not have a clinical background, however after many years of working with older people - many of whom are in last stages of life and/or are experiencing dementia - I have noticed a number of consistent patterns.

My own view is that as the dementia disease progresses, coping strategies that require good cognitive abilities appear to break down. Unresolved traumatic events, which may have been dealt with by disassociation or other forms of repression of memory, seem to insistently want to be heard.

I do not believe that dementia leads to dissociation.  I have seen evidence of older people, who have throughout their lives used disassociation as a coping mechanism around traumatic events, including sexual assault. However, due to the progression of the dementia individuals are somehow not able to continue using disassociation; this may lead to the person being back at the moment/s of trauma and not being able to use their historical dissociation coping mechanism.

Jill: Would you support the position that re-experiencing child sexual assault as an elderly woman could be wrongly diagnosed as dementia?

Rhonda: I'm not necessarily of the view that disclosure of childhood sexual abuse leads to a misdiagnosis of dementia. However, I have witnessed nursing and care staff dismiss disclosure of sexual abuse as being fanciful and part of the dementing process. Regardless of the nature of a dementia sufferer's disclosure, my own observation is it always makes sense if we fully know that person's history. Again, my personal view is that whatever coping processes a person has used to deal with traumatic life events seems to fail as the disease process of dementia progresses. The reliving of sexual assault, war trauma and any other traumatic event or loss is frequently being re-experienced with all the associated physical and psychological manifestations we would expect in a traumatised person.

Even though a person may not be experiencing dementia, I have found that it is not unusual for someone in the last stages of their life to want to disclose traumatic events they may never have spoken of before. Obviously this includes disclosure of sexual assault. Again, my personal view is that previous non-disclosure in respect to sexual assault may have been linked to a range of issues such as fear, a view that they were to blame in some way, that they would be tainted in other's eyes by the disclosure, or they may have made an initial disclosure which they retracted or did not pursue due to not being believed. These people are in their eighties and nineties, and this is probably the first time they have talked of the event. Their reasons for non-disclosure are pretty much the reasons that still prevail today. I suspect they disclose because as part of the dying process they realise that no one can hurt or judge them anymore, and they want to be heard and the assault acknowledged.

DISCUSSION FOCUS

Public education media campaigns

In Time for Action: The National Council's Plan for Australia to Reduce Violence Against Women and Their Children 2009-2021, the tenth recommendation is a social marketing strategy to promote behaviour change, and therefore prevent violence against women and their children. In conjunction with the emphasis throughout the plan on building an evidence base for each strategy taken, recommendation 10 presents a key opportunity for reflecting on the production and circulation of public education media campaigns.

The plan's social marketing focus has arrived into a climate of debate and discussion concerning the value, ethics, impacts, and effects of mobilising advertising to address issues such as sexual assault. In the United Kingdom in 2007, Emma Thompson's performance in a disturbing advertisement has been celebrated for drawing attention to the problem of sex trade trafficking. Two years later, an advertising campaign against domestic violence - starring another high profile actor, Keira Knightly - which depicted graphic violence was censored for television, despite strong arguments by its producers and sponsors that the shock of the violence was crucial to purpose of raising awareness (Johnston, 2009). In contrast, the most highly complained about advertisement on British television in 2008 - Bernardo's "Break the Cycle" campaign against child abuse - was permitted to continue airing because the aim of the campaign "justified the use of strong imagery" (Advertising Standards Authority, cited in Holmwood, 2009).

"Shock" advertising as social marketing in Australia has a powerful history, a continuing presence on television, and is linked to dramatic and broad behavioural changes and social attitudes. The 1987 Grim Reaper AIDS campaign is attributed with having a significant impact on the spread of AIDS in Australia by shocking mainstream audiences with the suggestion that AIDS was a concern for the general community (refer to Chapman, 2007). It is understood to be an integral part of Australia's success as "one of the swiftest and most successful responses to the virus in the world" (Raynor, 2007, p. 2).

It is perhaps also important to note that the advertising approach was taken to promote condom use in gay communities, which included the marketing of safe sex as "sexy" and "desirable". This has also been recognised, although less overtly, as playing a significant role in addressing the AIDS epidemic.

A number of "shock advertisements", characterised by the use of graphic, visceral imagery have also been credited with altering social attitudes to a range of behaviours such as drinking, drink driving, and smoking (Donovan & Henley, 1997).

Addressing issues of sexual violence and child sexual assault are perhaps some of the most fraught areas for education campaigns, with concerns about presenting offensive material; exposing children to traumatic themes and images; retraumatising survivors; or repeating the very discourses and frameworks of violence that the campaigns are seeking to address (e.g., Costello, 2004-05). There are also concerns about such campaigns targeting the victim of violence rather than the potential perpetrator - alienating or failing to engage a potential offender, but rather enabling or even provoking potential offenders of sexual violence to identify against the image of "the kind of man who does violence".

In this newsletter we begin what we hope will be an ongoing discussion of public education media, with a focus on the recent awareness campaign produced by Adult Survivors of Child Abuse (ASCA). ASCA is an Australian non-government organisation dedicated to the health and wellbeing of adult survivors of all forms of child abuse and neglect. The organisation campaigns on behalf of those affected by childhood abuse, lobbying governments and policy makers as well as educating and informing communities and health care professionals about the needs of those affected by childhood trauma. The focus on this paper revolves around their 2009 national advertising campaign, which is the largest Australian campaign ever to address the topic of adults surviving child abuse.1

This campaign has caused controversy. It has been both condemned as shocking and praised for the potential effect of that shock to raise awareness of the ongoing trauma experienced by survivors of child abuse. These diverse views have been expressed in online blogs, on radio program such as Radio National's Life Matters and the popular ABC television program that discusses advertising, The Gruen Transfer. It has also been discussed in the Senate. ASCA report that the campaign has increased the profile of the organisation with double the amount of callers to their telephone service and has caused "a healthy debate in our community" about the adult survival of child abuse (ASCA, 2009).

The campaign provides a powerful case study for reflecting on the production, circulation and consumption of public education media products. In February 2009, ASCA released the first phase of its campaign. This phase included the most controversial components of their national strategy.

Contributing to this discussion, Cathy Kezelman from ASCA reflects on the process of constructing the campaign, and the success the organisation has experienced through the increase of interest and access. Media commentator, copywriter, and former advertising executive, Jane Caro, has also reflected on her own experience of creating advertising. She brings this to bear on her own responses to the "Father of the Bride" television advertisement. Dr Leah Bromfield, Manager of the National Child Protection Clearinghouse, who has been working on a review of the literature concerning child safety media, and ACSSA's coordinator, Dr Antonia Quadara, have also provided reflections on public education media strategies more generally, and particularly in relation to the approach of Adult Survivors of Child Abuse.

References

Adult Survivors of Child Abuse. (2009). National advertising campaign. Retrieved from <http://www.asca.org.au/displaycommon.cfm?an=1&subarticlenbr=166>.

Chapman, P. (Producer). (2007). Rampant: How a city stopped a plague [Documentary]. Petersham, NSW: Chapman Pictures.

Costello, M. (2004-05). The disappearing "f" word: Feminism and Australian Government violence against women policies? Women Against Violence, 17, 41-49.

Donovan, R., & Henley, N. (1997). Negative outcomes, threats and threat appeals: Widening the conceptual framework for the study of fear and emotions in social marketing communication. Social Marketing Quarterly, Fall, 56-67.

Holmwood, L. (2009, April 29). Advert complaints over violence hit new high. The Guardian.

Johnston, I. (2009, April 27). Cuts demanded in Kiera Knightley's anti-domestic violence advert. The Telegraph.

Raynor, K. (2007). Rampant: How a city stopped a plague. A Study Guide. Atom

Constructing a controversial media campaign

Dr Cathy Kezelman

Despite the increased media coverage of abuse stories, there is very little community awareness of the long-term impacts of childhood sexual abuse. It is an area steeped in taboo, shame, stigma, and ignorance, and there is a pervasive attitude in our community that adults abused in childhood should simply be able to get over it. This attitude silences survivors, keeps them isolated and stops them getting the help they need. In addition, survivors' needs are poorly addressed in terms of services. Research in the area of trauma has not translated into education in universities and colleges, and survivors often report negative experiences when seeking help from services/practitioners. Trauma-informed services for adult survivors are few and far between in capital cities, let alone in rural and regional areas. Preference is given to recent cases of sexual assault and those in crisis. Until now there has been little to no government ownership of this issue, with no minister owning portfolio responsibility, no overarching policy, and no ongoing funding.

Adult Survivors of Child Abuse felt that a confronting media campaign was needed to shatter the taboo and stigma around the issues, and get people talking and thinking about the long-term impacts of child abuse for the first time. As one survivor said to us, the content of the campaign might appear insensitive to some, but it is far more insensitive to run a "feel good" campaign to ensure no one is offended. The reality is that being abused is shocking, and living with the repercussions of that abuse within a community that is complicit in perpetuating the silence and secrecy is devastatingly shocking.

The campaign was developed over more than 12 months with the input of survivors and practitioners in the field. It was tested during its development, and before its launch for sensitivities and messaging. The testing and discussions we went through before the launch suggested that the majority of survivors would understand and support the intention behind the campaign. The campaign is an integrated campaign across television, radio and print media, although the television component has received the most media attention. The television component specifically works to expose the myth "that it is easy to get over child abuse" and portrays a middle-class wedding scene at which the father reveals his crimes of incest against his daughter, and yet everyone laughs along. This depiction is an exaggeration of what society does to survivors by expecting them to laugh off their abuse and as shown in the advertisement, this silences the victims. The bottom line is that child abuse is no laughing matter, as any survivor knows only too well.

The radio and print advertisements address emotional, sexual, and physical abuse perpetrated on either gender by both men and women, as the organisation seeks to highlight the different forms of childhood trauma and tackle the stereotypes around gender.

This phase of the campaign has been effective in that it has started a healthy debate in the community about the legacy of child abuse. It has also seen unprecedented numbers of survivors coming forward, speaking out, and seeking help - enrolling in Adult Survivors of Child Abuse workshops and seeking membership. Change occurs slowly, especially one seeking to shift entrenched community attitudes around a taboo. Increased awareness is the first step towards understanding and then acceptance. This campaign has been controversial and we have had a lot of feedback on the campaign to which we have listened.

In April 2009 we released the second phase of our campaign. This phase entailed a set of three print advertisements, which received considerable exposure on fifty digital shop screens across the country, as well as in a variety of print and online media. This phase was less confronting and had a more targeted message with a honed call to action. It was supported by education programs within the health care community, as well as workshops for survivors and their supporters. Adult Survivors of Child Abuse will continue to take its message to the community and to government until we see acceptance, understanding, and appropriate support, as we have seen with other significant social and health issues in recent years.

Dr Cathy Kezelman is the Media Contact at Adult Survivors of Child Abuse.

What's wrong with the Adult Survivors of Child Abuse "Father of the Bride" campaign?

Jane Caro

Writing advertisements is highly skilled, highly specialised work. But let's not kid ourselves: in the end it is about selling something - a product, a service, or even a point of view. Advertising is ultimately about changing attitudes or behaviour and, sometimes, both. Advertising "creatives" (those responsible for designing ads) are usually practicing their craft in the areas of the trivial, the mundane, and the everyday. When it comes to dealing with subjects that are much more sensitive and highly charged, we can forget this - we can forget that we are entering a realm where vulnerable people are experiencing real suffering. For example, when I wrote campaigns for the NSW Police encouraging people to report child sexual abuse, I cast my own children in the commercials. The reason I did this was that I was pretty sure (as sure as any parent can be, I guess) that they had not been abused. I was terrified that I might unknowingly cast a child who had suffered abuse if I used traditional casting methods, and I worried that having to relive the experience (the advertisements were by no means graphic) - even in an advertisement - might do further damage.

Let me be quite frank about my view of the Father of the Bride campaign. I think the print is quite strong, but the radio - particularly the spot about child sexual abuse - and the television commercial, in my opinion, not only miss the mark, but also may do actual harm. The television commercial loses me when it makes the victim - the bride - complicit in her own abuse. When she laughs and mouths along with her father, "don't tell mum", I am left with a feeling of revulsion, not only at the topic, but also at the advertisement itself. (The radio advertisement, by having the bride talk in a light-hearted manner about her father "raping" her as the wedding guests laugh appreciatively, compounds the felony.)

Perhaps it could have been different if we had watched the bride's face slowly crumple and collapse as her father makes his extraordinary and shocking speech, perhaps then I would have been able to think more about the tragedy of child abuse, rather than simply about my shock at the insensitivity of the advertisement. I cannot help but dread what a 12 or 13 year old girl currently being abused by a parent must feel when she sees this commercial. What message does she receive, except that daddy is right, and that this is trivial - a bit of fun - even a bit of a laugh? Her experience of men who are meant to protect her has been that they will instead exploit and use her for their own gratification. To me, this advertisement seems to be doing the same thing.

Worse, we know many victims of child abuse feel tremendous shame about what has happened to them because they feel they were complicit and may even have experienced sexual pleasure. We also know this makes no difference to the moral responsibility. A child is never complicit in his or her own abuse by an adult, particularly by a loved and trusted parent. Yet this advertisement runs the risk of increasing a victim's shame, and so keeping them silent about their suffering.

And I don't buy the argument that this advertisement's shock value is needed to get us talking about the issue. It hasn't done that at all. What it has done is got us talking about the advertisement. It has vamped the issue and that seems the wrong way round to me. It also doesn't tell me what to do about child abuse. As Dan Gregory said on The Gruen Transfer, the viewer has nowhere to go with this advertisement, except into rage and revulsion. Moreover, it ends by telling victims it is really, really hard to recover from the effects of their abuse. I bet that really cheers them up.

The majority of people who write, create, and approve advertising in Australia are men. Many of them are men with the very best of intentions, and some of them have a sensitivity and empathy that enables them to write advertisements that appeal to all sorts of people no matter who they are. Perhaps, however, it is harder for a man to imagine what it must be like to be an abused 13 year old girl, utterly confused and bewildered about the behaviour of the man who claims to love and protect her. It is hard for even the best-intentioned heterosexual men to understand how it feels to be despised and exploited sexually by those more powerful than you. The recent 4 Corners program on the damage done to young women by the sexual aggression of rugby league footballers is a case in point. These powerful - in every sense of the word - young men seemed to regard their transgression as simply a bit of fun or, at worst, something they should apologise to their wives and children for. The abused girls all said they felt worthless, as if they had been treated like garbage and then cast aside. I believe that anyone attempting to write about such abuse needs to work with the very highest level of respect, empathy, and humility - constantly aware of how little they actually know. To do the job properly they must imaginatively and painfully enter the world of the despised, the abused, and the powerless. To do otherwise risks creating another form of abuse.

I have no doubt everyone involved in the production of this advertisement had only the very best of intentions. But this is child abuse observed - from an outsider's perspective - rather than child abuse empathically and sensitively imagined. What is missing entirely is the victim's point of view.

Jane Caro is a freelance writer, media commentator, and a lecturer at University of Western Sydney.

The effectiveness of social marketing campaigns: The recent Adult Survivors of Child Abuse "Father of the Bride" advertisement

Dr Leah Bromfield

Traditionally, the public have seen sexual assault prevention as a responsibility for women to "stay safe". Similarly, public expectations of sexual assault victim/survivors are for them to work towards recovery. As a sector, there is recognition of the need for prevention and responses to sexual assault to focus on changing community attitudes, awareness, and responses. To support this goal we increasingly turn to mass media campaigns.

A recent Adult Survivors of Child Abuse (ASCA) television advertisement depicts the father of the bride giving a speech at his daughter's wedding in which he jokes with the groom about his daughter being a "good lay", and shares a joke with his daughter about "not telling mum". On first viewing I found myself sitting up and paying attention, feeling first shock, then offence, and finally curiosity as I finally got to the point of thinking "what's this all about?". The tag line at the end of the advertisement is "if only it were that easy to recover from sexual assault". The advertisement is provocative - and deliberately so. The campaign appears to be attempting to shock with an extreme position that will cause audiences to feel much like I did, and then of course agreeing with the tag line that it is not that easy to recover from sexual assault.

The advertisement has had mixed responses from the community and from victim/survivors themselves - some who have loved it, and others who have found it very offensive and distressing. Personally, I don't like the advertisement, and yet I can agree wholeheartedly with the intent.

I have tried to reflect on this, and to consider what it is about the campaign that has failed to win me over. If we take media campaigns in the sector, they aim to prevent or change responses to sexual assault and child sexual abuse by raising awareness or enhancing the audiences' knowledge about a specific subject, changing attitudes, or changing the behaviour of the target audience towards the specific subject matter (or a combination of the three). My concern regarding the advertisement is that I am not clear which of these aims is being pursued.

One of the aims could be to increase knowledge and awareness about the long-term effects of child sexual abuse - survivors can struggle with the effects for their entire lives - and yet the advertisement does not increase awareness of what these effects are. The advertisement could be attempting to change attitudes - to have the community recognise that sexual abuse is not something that you just get over - but the counter-point of the father-of-the-bride speech is so extreme that the audience can immediately reject it, and it is not clear what attitudes we want to change. Finally, the advertisement does not offer alternate positive behaviours or responses.

My other concern is with the structure of the advertisement itself - the main content of the father of the bride speech is emotive, whereas the tag line is subdued, in text only, and is right at the end. The success of the advertisement hinges upon audiences putting together the provocative content and the tag line, but I have concerns that viewers - particularly if they have a strong emotional response - will fail to attend to the tag line at the close of the commercial.

These are my personal views. I don't know if the commercial has - or will be - a success, which raises a crucial issue: while the use of media campaigns is widespread, few campaigns have been evaluated for impact or achieving behaviour change. If the sector is to achieve its goals of changing community attitudes, awareness, and responses to sexual assault (and to do so without further distressing victim/survivors), there is a need for research that informs us of the components of effective social marketing campaign in this field.

Dr Leah Bromfield is the Manager of the National Child Protection Clearinghouse at the Australian Institute of Family Studies.

Public media campaigns in responding to and preventing sexual assault: A summary of the research

Dr Antonia Quadara

There have been many public education campaigns that have aimed to raise awareness of violence against women. Indeed, this has become an increasingly crowded and sophisticated space. Some of the more recent examples include:

The advertising campaign by Adult Survivors of Child Abuse discussed in the preceding articles sparked debate about what their aims and purpose were, what they ought to have been, and whether the strategy was successful. In the recently released National Plan, the Australian Government has endorsed the development of a social marketing campaign to address violence against women, and has committed $17 million to this.

It is timely therefore to consider what the current state of play is with regards to the development and deployment of such campaigns. What are social marketing, public awareness, and social norms campaigns? Is there agreement among the key players about what any of these terms refer to? What counts as success and how is it ascertained? Although there have been numerous campaigns addressing violence against women broadly, where does sexual assault fit within the issue? Are there particular challenges in using mass media and marketing strategies to address sexual assault? This summary synthesises the recent research literature in response to these questions.

Social marketing, public education and social norms campaigns

A recent review of social marketing campaigns addressing violence against women noted that there was "considerable confusion surrounding the use of the term ... by health and social change organisations" (Donovan & Vlais, 2005, p. 4). There is often confusion about whether social marketing describes all forms of media campaigning, including public awareness raising, whether it is (or should be) restricted to more specific goals, or whether it is a tool, a process, or a framework.

The review by Donovan and Vlais (2005) described social marketing as "the application of the concepts and tools of commercial marketing to the achievement of socially desirable goals" (p. 4). These goals may refer either to individual change, or change at a more collective level (neighbourhood, community, policy). The primary paradigm used is a marketing one, meaning that it involves:

Based on the review of campaigns (both national and international), the authors described four different types. These are listed and described below.

Type Description Examples

General or specific awareness campaigns

  • Primary objective of increasing awareness and knowledge of particular issues relevant to violence against women
  • Community at large usually the primary target audience, but some explicitly target specific sub-groups (e.g., perpetrators, bystanders, friends)
  • Violence Against Women: Australia Says No
  • UNIFEM Australia White Ribbon Day
  • Safe At Home - TAS
  • Let's Stop It ... Now - NT

Campaigns targeting men who engage in violence against women to voluntarily seek help
  • Primarily target adult men who are already engaging in violence or at high risk of doing so
  • Freedom From Fear - WA
  • Walk Away, Cool Down - QLD

Primary and secondary prevention campaigns

  • Typically target young men and women
  • Some focus on the early development signs of violence and controlling behaviours
  • Some focus on bystander education
  • No Respect, No Relationship - Commonwealth (didn't run)
  • Expect Respect - NSW

Social norms campaigns
  • Based on idea that social and cultural constructions of masculinity, gendered power relations and attitudes/beliefs provide a normative background that condone and facilitate men's violence against women
  • Aim to correct misperceptions of existing norms and/or challenge existing norms
  • Violence Against Women: It's Against all the rules - NSW

(Adapted from Donovan & Vlais, 2005)

Although the review of campaigns since 1995 is very useful for obtaining a sense of how different campaigns have operated, it is somewhat limited in that the classification arose out of "observing the types of campaigns identified rather than on an underlying theoretical and conceptual framework" (Donovan & Vlais, 2005, p. 10). If those working in the media and social change space are themselves taking social marketing to mean different things, this may mean a lack of conceptual robustness in working definitions of social marketing.

Conceptual histories

A significant literature and evidence base exists on the use of mass media, communications, and marketing as strategies for social change. This work draws from psychology, marketing, sociology, economics, and public health disciplines (some of these resources are listed at the end of this article).

The concept of social marketing has developed since the 1950s when it was closely aligned with the marketing of products involved in social change (e.g., condoms, the pill) to a broader conception involving changing behaviour as the goal. The evidence base for social marketing practices is based on interventions in, for example, drink driving, wearing seatbelts, and smoking. There are six characteristics of social marketing:

Andreasen (2002), a key scholar in the field, observes "social marketers, both scholars and practitioners, have come to accept that the fundamental objective of social marketing is not promoting ideas but influencing behaviour" (p. 4), further stating:

Increasing the acceptability of a social ideal is not what social marketing is all about. As in the private sector, the ultimate objective should be behaviour change ... if you don't move the needle, you are not being a successful marketer. Simply gaining acceptance of an idea without inducing action is not success. Indeed this approach is more appropriately labelled "education" or "attitude change". (Andreasen, 2002, p. 4,7)

In other words, attitude change does not equal behaviour change. Further, according to this view, public education and awareness raising are not social marketing, in that behaviour change may not be the primary objective or, where it is, knowing more about an issue may not actually lead to changes in behaviour.

In contrast, other research uses the terms "public communications" and "public will" campaigns (Coffman, 2002; Doorman, Ervice, & Woodruff, 2002; Salmon, Post, & Christensen, 2003) precisely to describe the use of the media, messaging, and strategic communications to guide behaviour towards socially desirable outcomes. This literature identifies two different types of campaigns: those that focus on individual behaviour change (also called public information or public education campaigns), and those that focus on public will and political change (Coffman, 2002). Social marketing here is not a framework guiding action, but is one strategy to achieve behaviour change goals (see the table below).

Goal Individual Public will

Objectives
  • Influence beliefs and knowledge about a behavior and its consequences
  • Affect perceived social norms about the acceptability of a behavior among one's peers
  • Affect intentions to perform the behavior
  • Produce behaviour change
  • Increase visibility of an issue
  • Affect perceptions of social issues and who is seen as responsible
  • Increase knowledge about solutions
  • Mobilise constituencies to action

Target audience

Segments of the population whose behaviour needs to change

Segments of the general public to be mobilised and policy makers

Strategies

Social marketing

Media advocacy, community organisation and mobilisation

Media Vehicles
  • Public service/affairs programming
  • Print, television, radio, electronic advertising
  • News media
  • Print, television, radio
  • Electronic advertising

(Adapted from Coffman, 2002, p. 6)

Social norms could be considered a particular strategy, or set of tools, within a social marketing approach. Social norms theory describes "situations in which individuals incorrectly perceive the attitudes and/or behaviours and other community members to be different from their own when in fact they are not" (Berkowtiz, 2004b, np). An example is college students' overestimation of how much alcohol their peers drink which has been correlated with an individual's heavy or unsafe drinking patterns (Berkowitz, 2004b). It then follows that correcting misperceptions by revealing the "actual, healthier norm" will have beneficial effects on most people.

In short, it would seem that there are several terms currently in use to describe the use of media campaigns in social change, and that there are differences in how social marketing functions within different frameworks. Despite the messiness of terminology and disagreement across the literature, a number of shared understandings are evident:

A raft of other actions are required to embed both the campaign and the issue in the community, such as:

Evaluating campaigns

Determining the design, effectiveness and impact of social marketing campaigns involves four different types of evaluation:

How does the target audience think about the issue? What messages work best with which audiences? Who are the best messengers? What theory of change informs this?

How many materials have been put out? What has been the campaign's reach? Did it reach the target audience?

Has there been any affective change (in beliefs, attitudes, social norms) in comparison to the baseline information? Has there been behaviour change?

Has the behaviour resulted in its intended effects (e.g., lower rates of violence against women)? Has there been any system level changes?

(Adapted from Coffman, 2002, p. 13; see also Andreasen, 2002; Donovan & Vlais, 2005).

Another way of assessing a public media campaign is to consider its purpose, scope and maturity (Dorfman et al., 2002). This can be used as a way to avoid the "muddled jargon" variously describing communication campaigns (Dorfman et al., 2002, p. 4). Purpose is considered the most important consideration, the ultimate goal of which is either to affect individuals directly or the collective policies that shape behaviour. Scope considers the size and extent of a campaign: how far does a campaign reach, over what region, and over what time period? The level of maturity describes whether a campaign is a one-off or whether it lasts for years. It can also refer to issue maturity (i.e., how old an issue is), and how the social understandings of a problem have changed over time.

The Framework for Effective Campaigns identified four characteristics of effective public media campaigns: capturing the right audience; delivering an understandable and credible message; delivering a message that influences beliefs or knowledge; and creating social contexts that lead to desired outcomes (Weiss & Tschirhart, 1994, cited in Coffman, 2002). However, there are significant challenges in trying to obtain this evaluative information.

Challenges for evaluation practice

Challenge 1: Lack of theory

VicHealth's review of social marketing strategies in the violence against women sector (Donovan & Vlais, 2005) found that in many cases, few formative evaluation had been undertaken, there were few impact evaluations and even fewer that were publicly available and that, broadly speaking, explicit theories of change were not evidenced. In other words it wasn't made clear how the relationship between goals, design, and behaviour change outcomes was understood. The research literature suggests that this is a problem at the level of design and evaluation:

What is missing from most of the process models is any kind of underlying theoretical framework ... they do not tie steps to any particular framework that makes clear how what they do is supposed to work to impact crucial social behaviours. (Andreasen in Coffman, 2002, p. 17)

A number of theories about behaviour change from the social sciences have been identified as useful to linking goals, design, outcomes, and measures - for example, Theory of Reasoned Action, Social Cognitive Theory, Health Belief Model, and Stages of Change Model (see Coffman, 2002, p. 17-18 for summary).

Challenge 2: The conundrum of purpose

The literature tends to make a distinction between individual and collective interventions, and this may be especially pertinent to determining impact and success. However, it can generate ethical and political divides; a focus on the individual may obscure the social conditions for behaviour, while collective level interventions are difficult to measure, and may have difficulty going beyond a public awareness campaign. Dorfman et al. (2002) consider this a false dichotomy stating: "personal choices are always made in the context of a larger environment" (p. 5). Purpose may be considered a continuum of reform, with individual and collective strategies targeting different dimensions of behaviour. This framing doesn't necessarily alleviate the challenge the definition of purpose brings, such as: lack of clarity in purpose; having multiple purposes; ambiguity or lack of connection between goals and actions; or no preferable or clear desired outcome (e.g., calling a helpline). Moreover, evaluations themselves need to have clarity about their purpose (clarity about unit of analysis): "what is it that the evaluation wants to say something about - individuals? strategies for behaviour change? attitude change?" (Dorfman et al., 2002, p. 35).

Challenge 3: Resources (time, funds, skills)

Evaluations are expensive and complicated in that their conditions cannot be controlled. Often, evaluation may happen at the end of the campaign rather than be built into the design. This can mean a lack of familiarity with the campaign goals, or an outcome evaluation with measures not suited to how the campaign was designed. Finally, determining impact can be difficult in that impacts may take many years to become evident. Are there interim measures that can be used for evaluations, which are usually on a much shorter timeline?

Challenge 4: Specific challenges for the sexual assault sector

In giving consideration to the previous challenges, it would appear that there are factors specific to the sexual assault sector that make the design, implementation, and evaluation of public communications and social marketing campaigns particularly complex. These are:

Lack of consistent messaging. Much of the empirical knowledge base about what works in social marketing has arisen from the tobacco, car and road safety, and alcohol sectors. Here, there has been a consistent messaging about the problems of these behaviours, their effects and what individuals can do to change behaviour. It isn't clear that this consistency is evident in the sexual assault sector. As many feminist commentators have noted, entrenched attitudes about both sex and sexual violence shape public education messages (see Carmody 2003, 2009 for a review) with the effect that risk avoidance campaigns for young women, challenging social norms about masculinity and victim support campaigns can all exist in the same "message space".

The hegemony of patriarchy and rigid hyper masculine gender roles are deeply ingrained in individuals, families, social customs, laws, institutions - indeed in virtually every facet of living - then the work of change that culture and the individuals living by its rules is enormous. (p. 5)

He argues that a social norms approach can mitigate the amplification of risk and fear that some awareness campaigns inadvertently create, as well as offering a way forward when prevention work becomes overwhelmed, because a social norms approach is not so much about creating new social norms, but about challenging misperceptions that certain practices, beliefs or attitudes are normal.

References

Andreasen, A. (2002). Marketing social marketing in the social change marketplace. Journal of Public Policy and Marketing, 21, (1), 3-11.

Berkowitz, A. (2004a). Working with men to prevent violence against women: An overview. Retrieved from: <http://new.vawnet.org/category/Main_Doc.php?docid=413>

Berkowitz A. (2004b). The social norms approach: Theory, research and annotated bibliography. Retrieved from: <www.alanberkowitz.com/articles/social_norms.pdf (PDF 200 KB)>

Coffman, J. (2002). Public communication campaign evaluation: An environmental scan of challenges, criticisms, practice, and opportunities. Retrieved from: <www.hfrp.org/publications-resources/browse-our-publications/public-communication-campaign-evaluation-an-environmental-scan-of-challenges-criticisms-practice-and-opportunities>

Donovan, R. J., & Vlais, R. (2005). VicHealth review of communication components of social marketing/public education campaigns focusing on violence against women. Melbourne: Victorian Health Promotion Foundation.

Dorfman, L., Ervice, J., & Woodruff, K. (2002). Voices for change: A taxonomy of public communication campaigns and their evaluation challenges. Berkeley Media Studies Group: Berkeley, CA.

Fabiano, P., Perkins, W., Berkowitz, A., Linkenbach, J., & Stark, C. (2004). Engaging men as social justice allies in ending violence against women: Evidence for a social norms approach. Retrieved from: <www.alanberkowitz.com/articles/MenAsAllies.pdf (PDF 2.3 MB)>

Salmon, C. T., Post, L. A., & Christensen, R. E. (2003). Mobilizing public will for social change. Lansing, MI: Michigan State University.

Dr Antonia Quadara is the Coordinator of the Australian Centre for the Study of Sexual Assaulat the Australian Institute of Family Studies.

Literature highlights

Compiled by Carole Jean, Librarian

The following are a selection of resources addressing current issues in the sexual violence field. In this edition of Aware, we focus on surviving sexual assault trauma and dementia and also on prevention campaigns and media. ACSSA receives many of these resources. Print resources are available via the interlibrary loan system. Contact your local library for details. Electronic resources are available directly via the web address. The inclusion of a publication in this list does not necessarily mean that it is endorsed by ACSSA.

Surviving sexual assault trauma and dementia

Unresolved childhood sexual abuse: Are older adults affected? (1992). Allers, C. T., Benjack, K. J., & Allers, N. T. Journal of Counseling and Development, 71(1), 14-17.

This article presents case studies and discussions regarding observed characteristics of unresolved childhood sexual abuse in adult survivors over 65 years of age. Specifically chronic depression, elder abuse, and the misdiagnoses of residual abuse trauma as dementia or mental illness are compared to parallel issues identified by researchers in younger adult survivors. A brief overview of the childhood abuse literature and recommendations regarding professional training, the development of new services, and additional research are included.

Rural Tasmanian dementia health care model. (2003, March). Campbell-Smith, M. Paper presented at Seventh National Rural Health Conference, Hobart. Available online only at: <http://nrha.ruralhealth.org.au/conferences/docs/7thNRHC/Papers/general%20papers/campbell-smith.pdf (PDF 399 KB)>

Alzheimer's and vascular dementia diseases are both difficult to diagnose. The author discusses specific and flexible strategies that are needed to assist carers of people suffering dementia in rural and remote areas. The work of the rural Westbury Community Centre in Tasmania which assists clients and carers of people with Alzheimer's disease is described and some of the difficulties of living with dementia, like reactions to over stimulation and revisited trauma are outlined. Access to the centre, client assessment, the services the centre offers to carers, and working with general practitioners, community nurses and the community, are also covered.

Late-life paranoia: Possible association with early trauma and infertility. (1992). Gurian, B. S., Wexler, D., & Baker, E. H. International Journal of Geriatric Psychiatry, 7(4), 277-284.

Studied data on 39 persons (aged 60-93 yrs) with late-life onset of paranoid symptoms. A subset of 9 female Ss met the criteria for delusional disorder (DD). DD Ss differed significantly from demented and long-term schizophrenic Ss on a number of variables. Among the DD Ss, (1) there was only 1 live birth, (2) more than half were refugees or holocaust survivors, (3) there was an absence of a predicted sensory loss, and (4) the manifestation of the paranoia was qualitatively different. Discussion addresses the existence of a late-life delusional state that is neither schizophrenia nor dementia and indicates that the paranoia in DD Ss cannot be accounted for exclusively by a social isolation hypothesis. Also considered is the interaction among early trauma, absence of children, and appearance of paranoid ideation late in life.

When late life brings a diagnosis of Alzheimer's disease and early life brought trauma. A cognitive-analytic understanding of loss of mind. (2003). Sutton, L. Clinical Psychology & Psychotherapy, 10(3), 156-164.

This paper contrasts the loss of mind from the loss of brain cells in Alzheimer's disease and other neurodegenerative conditions with the threats to one's mind from the mindlessness of others from a cognitive-analytic perspective. Case studies are presented that show how the therapeutic framework of Cognitive-Analytic Therapy (Ryle, 1990, 1995, 1997) can bring containment for both client and therapist for clients facing this dilemma, particularly when past trauma is potentially overwhelming. This is set in a dialogue with the pioneering work of Tom Kitwood (1990,1995,1997) in dementia care, in which Kitwood's thesis of the "malignant social psychology" surrounding people with dementia is re-stated in terms of "reciprocal roles" developed in Cognitive-Analytic Therapy.

Sexual violence, post-traumatic stress disorder, and dementia. (1997). McCartney, J. R., Severson, K. Journal of the American Geriatrics Society, 45(1), 76-78.

Little is known of posttraumatic stress disorder (PTSD) in older people. No literature exists on this disorder in older women exposed to sexual assault. A case of apparent PTSD in an 82-year-old demented woman raises questions of the anatomy and phenomenology of this disorder. Difficulties in diagnosis in a demented population may cloud the issues or prevent a proper therapeutic outcome.

A series of cases of dementia presenting with PTSD symptoms in World War II combat veterans. (2000). Johnston, D. Journal of the American Geriatrics Society, 48(1), 70-72.

There is a large cohort of WWII veterans at risk for, or already diagnosed with, dementia. However, there is little or no information about the relationship between posttraumatic stress disorder (PTSD) and dementia. A series of cases are presented describing WWII and Korean combat veterans (aged 68, 77, and 78 yrs old) seen at a VA Medical Center in whom the onset of dementia was heralded by symptoms consistent with a diagnosis of PTSD. Although in all 3 cases cognitive impairment had been evident, help was not sought until a violent outburst occurred. The event was associated with a recent history of nightmares of wartime experiences, physiological hyperreactivity with exaggerated startle response, and tremulousness and pallor in response to evocative stimuli. The sudden outbursts of violence were accompanied by periods of withdrawal, dysphoria, tearfulness, and preoccupation with wartime experiences. Implications of these cases for ageing veterans are discussed.

Contribution of PTSD/POW history to behavioral disturbances in dementia. (2001). Verma, S., Orengo, C. A., Maxwell, R., Kunik, M. E., Molinari, V. A., Vasterling, J. J ., & Hale, D. D. International Journal of Geriatric Psychiatry, 16(4), 356-360.

As many WW II and Korean Conflict veterans suffering from posttraumatic stress disorder (PTSD) grow older, increasing numbers will be diagnosed with dementia. The authors retrospectively analyzed patients with dementia, comparing the behavioral disturbances of those with vs without PTSD. It was hypothesized that due to the additive effect of the neurobiological and behavioral changes associated with PTSD and dementia, the dementia with PTSD group would show more agitation and disinhibition than the dementia without PTSD group. 16 Ss with diagnoses of dementia and PTSD were matched on age and Mini-Mental States Examination scores to 16 Ss with dementia without PTSD. Ss with diagnoses of dementia with PTSD did not differ significantly in their clinical presentation, hospital course, and condition at discharge from Ss with dementia without PTSD. Significantly more PTSD Ss were prescribed anti-depressants compared to the non-PTSD group. Within the PTSD group, the subgroup of Ss who were former POWs had a higher mean score for paranoia and less verbal agitation. This study reveals that a diagnosis of PTSD alone is not sufficient to influence behavior in veterans with dementia; however, the authors also present provocative results that patients with more severe trauma (POW) do have changes in their behavior.

Emergence of PTSD in trauma survivors with dementia. (2001). van Achterberg, M. E., Rohrbaugh, R. M., & Southwick, S. M. Journal of Clinical Psychiatry, 62(3), 206-207 [Letter].

Postraumatic stress disorder (PTSD) usually emerges soon after a traumatic event. However, some trauma survivors may experience the full-blown syndrome for the first time as they age. In a recent case series, D. A. Johnson (see record 2000-13202-004) described 3 WWII veterans in whom onset of dementia was heralded by an exacerbation of PTSD symptoms. This report describes 3 additional patients who also experienced a marked increase in PTSD symptoms after onset of dementia, only 1 of whom was a war veteran. Patient 1 was a 95-yr-old nursing home patient who had survived the sinking of the Titanic. She began demonstrating extreme psychomotor agitation, accompanied by vivid reexperiencing of her earlier trauma. Patient 2 was a 75-yr-old WWII veteran who began demonstrating signs of cognitive impairment and physical violence, and perseverated on war memories. Patient 3 was an 83-yr-old female who had been traumatized during the Holocaust. Over the years she experienced occasional intrusive memories, and had begun having difficulties with memory and executive functioning. In the 3 cases presented, symptoms of PTSD worsened dramatically after the onset of dementia. Several possible explanations for an association between declining cognitive function and increasing PTSD symptoms are discussed.

Sexual abuse, trauma and dementia in the elderly: A retrospective study of 284 cases. (2006). Burgess, A. W., & Phillips, S. L. Victims & Offenders, 1(2), 193-204.

The study objective was to compare elders with a dementia with those without a dementia as to method of disclosure of sexual abuse, forensic markers of sexual abuse and legal outcome of cases. A convenience sample was obtained of 284 forensic cases known to a multidisciplinary group of professionals who investigated, examined or consulted on elder sexual abuse victims. The Comprehensive Sexual Assault Assessment (CSAAT) was used to enter data from case files. 60 percent of the 284 elders were diagnosed with some degree of dementia. Elders with dementia, compared to those without a diagnosis, were abused more often by persons known to them (family member, caregiver or another nursing home resident) than a stranger, presented behavior cues of distress rather than verbal disclosures, were easily confused and verbally manipulated, and were beaten. Suspects who were identified whom abused elders with dementia had less chance of being arrested, indicted or plea bargained. All reported suspected cases of elder sexual abuse need a complete physical examination as well as a sexual assault evidence kit. Patterns of verbal, behavioral or physical changes of elders can be used to support an allegation of sexual assault.

Worsening of post-traumatic stress disorder symptoms with cognitive decline: Case series. (2001). Mittal, D., Torres, R., Abashidze, A., & Jimerson, N. Journal of Geriatric Psychiatry and Neurology, 14(1), 17-20.

Presents 3 cases of post-traumatic stress disorder (PTSD) symptoms associated with cognitive decline. All patients were males (aged 57-70 yrs) and had war-related PTSD. In each case, the patient had a history of PTSD that was under fairly good control until the onset of cognitive impairment due to Alzheimer's disease or vascular or alcohol-related dementia. These cases suggest that neurodegeneration of memory pathways may disinhibit symptoms of PTSD.

Prevention campaigns and media

A media campaign prevention program for child sexual abuse: Community members' perspectives. (2008). Self-Brown, S., Rheingold, A. A., Campbell, C., & de Arellano, M. A. Journal of Interpersonal Violence, 23(6), 728-743.

This study examines the face validity and feasibility of materials included in a multimedia child sexual abuse (CSA) prevention campaign. A quantitative survey method assessed participants' comfort level, knowledge gain, and likelihood of behavioral change in response to the media campaign. Furthermore, a focus group method explored participants' attitudes and opinions regarding the campaign and the unique effects of ethnic or cultural norms on participants' acceptance of the media materials. Six groups, established based on participant ethnicity (i.e., three Caucasian groups, two African American groups, one Hispanic group), met at two sites in the Charleston, South Carolina, area. Quantitative data suggest that participants reported increased CSA knowledge and low levels of discomfort or anxiety related to exposure to the materials. Focus group results suggest that study participants, regardless of ethnic background, agreed that the media campaign can have a positive impact on public knowledge of CSA. Implications and directions for future research are discussed.

Prevention of child sexual abuse: Evaluation of a community media campaign. (2007). Rheingold, A. A., Campbell, C., Self-Brown, S., de Arellano, M., Resnick, H., & Kilpatrick, D. Child Maltreatment, 12(4), 352-363.

Given that mass media techniques have been an effective tool within the public health field for affecting behavioral change, these strategies may prove successful for the primary prevention of child sexual abuse (CSA). This study was an independent evaluation of a CSA media campaign. Two hundred parents were recruited from eight sites across the United States. Results indicated that the combined mass media campaign affected knowledge about CSA at the time of intervention compared to no intervention. No significant differences were found in regards to CSA attitudes. A significant positive impact on primary prevention response behaviours assessed using hypothetical vignettes was found; however, no significant findings were noted for several other behavioural responses. Knowledge and behavioural gains were not maintained at the one-month follow-up. Small sample size at follow-up may have affected findings. Results of this study imply that media campaigns alone may not significantly affect primary prevention of CSA.

The role of the mass media in facilitating community education and child abuse prevention strategies. (2002). Saunders, B. J., & Goddard, C. (Child Abuse Prevention Issues No.16). Melbourne, Vic: National Child Protection Clearinghouse, Australian Institute of Family Studies. Available at: <http://www.aifs.gov.au/nch/pubs/issues/issues16/issues16.html>

In the second part of an analysis of the role of mass media in child abuse prevention, the benefits of mass media programs as a tool to advocate for children's rights are discussed and more specifically, to promote awareness of, and to prevent, child abuse. (The first part appeared as Issues paper no.14: Child abuse and the media.) The authors emphasise that campaign strategies may only be successful to the degree that they are backed by community education and direct support programs. Information gained from evaluations is highlighted, and recommendations for future media campaigns and initiatives are made.

Child abuse and the media. (2001). Goddard, C., & Saunders, B. J. (Child Abuse Prevention Issues No.14). Melbourne, Vic: National Child Protection Clearinghouse, Australian Institute of Family Studies. Available at: <http://www.aifs.gov.au/nch/pubs/issues/issues14/issues14.html>

This paper examines the role of the media in relation to child abuse and child protection and argues that the media have been essential to the task of placing the problem of child abuse in the minds of the public and on the political agenda. The media have played a major role in defining what is "normal" and what is "deviant" in society, thus contributing to definitions of what is, and what is not, considered to be child abuse. Significantly, the media have appeared, at times, to have more influence on child protection policy and practice than professionals working in the field - a phenomenon described as "legislation by tabloid". While acknowledging that the media's portrayal of child abuse and child protection can have negative consequences for children and their families, it is argued that media coverage is vital if public concern for children is to remain on the political agenda, and if child protection services are to remain accountable.

Endnote

1. See <www.asca.org.au/displaycommon.cfm?an=1&subarticlenbr=166> for more information on ASCA and their media campaign. The ASCA website includes a link to the controversial “Father of the Bride” advertisement which has provoked this discussion.

Disclaimer

The Australian Institute of Family Studies is committed to the creation and dissemination of research-based information on family functioning and wellbeing. Views expressed in its publications are those of individual authors and may not reflect Australian Government or Institute policy, or the opinions of the Editors or of the Director.