- Building the capacity of staff is the cornerstone of any facility’s ability to address violence against women and girls in an ethical and effective way. Too often, especially in resource-poor settings, staff does not receive adequate training and support: if they receive training at all, it is often a single training with limited to no follow-up.
- In general, facilities should consider the following key activities to build staff capacity:
- All staff, from facility administrators to service providers to support staff, should first be sensitized about issues related to violence against women and gender discrimination. Evidence suggests that health professionals are as likely as any other members of society to hold views that may be detrimental to the welfare of survivors, such as blaming the victim. Staff also need to have a basic understanding of the nature and scope of violence against women and girls, the dynamics of abuse, risk factors and consequences.
- Specialized staff, including all medical professional providing direct services to survivors, should receive additional and ongoing training on key elements related to intake, examination, record keeping, etc.
- Specialized staff should also receive ongoing support to manage the challenges of working with survivors, through supervision, in-service trainings, case reviews, etc.
3a. Step One: Conduct staff assessments.
- Prior to implementing sensitization and training, it is useful to conduct staff knowledge, attitudes, and practice (KAP) assessments to determine the level, scope and type of sensitization and training that will need to be conducted for different staff members (reception, nurses, doctors, specialists). In addition, this information can be used to documents a baseline so that health programmes can measure changes in providers’ knowledge, attitudes, and practices over time. The KAP staff assessment should cover:
- Personal perceptions, attitudes and beliefs related to violence against women and girls
- Knowledge of gender issues and human rights
- Understanding of the legal framework, national policies and protocols
- Technical skills (medical and non-medical) related to addressing violence against women and girls
- Methods for collecting information on providers‘ knowledge, attitudes, and practices are described below, and include surveys and gathering qualitative data through group discussions or other participatory methods with providers. Qualitative data can provide an in-depth understanding of providers‘ perspectives. Quantitative data makes it easier to measure change over time.
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KAP Staff Assessment Method |
Comparative Usefulness |
Sample Tools |
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Surveys |
Surveys offer information about:
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When conducting surveys, it is best to use or adapt already designed and validated instruments and questions, including from the:
Gender-Equitable Men (GEM) Scale (Horizons and Promundo). The scale measures attitudes toward gender-equitable norms in order to provide information about prevailing norms in a community and the effectiveness of programmes hoping to influence them. It can be adapted for use with health care providers. Available in English, Spanish and Portuguese.
Personal Assessment for Advocates Working with Victims of Sexual Violence (The National Resource Sharing Project and the National Sexual Violence Resource Center, 2010). This tool was developed to assist those working with victims of sexual violence in identifying strengths and strategies to improve their practice. The assessment is available in English.
The Attitudes Towards Rape Victims Scale (The Arizona Rape Prevention and Education Project). These scales are self administered instruments designed to assess individuals‘ attitudes towards rape victims rather than towards rape in general. Available in English.
The Sexual Violence Research Initiative compiled a comprehensive package of programme evaluation tools and methods for assessing service delivery, knowledge, attitudes, practices and behaviours in sexual violence projects and services. By making such materials available to service providers, managers, researchers, policy makers and activists, among others, the hope was that evaluation could be more easily incorporated into project and programme plans. The assessment instruments are drawn from articles in peer-reviewed journals that report findings from evaluations of health care-based services and interventions for women victims/survivors of sexual violence, written in English or Spanish, published between January 1990 and June 2005. The instruments are available from the evaluation section of sexual violence research initiative website. |
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Semi-structured interviews |
SSIs offer insight into providers‘ knowledge, attitudes and practices; and offer the potential for digging deeper into any challenges, barriers, concerns that may affect ability to provide care.
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International Planned Parenthood Federation, Western Hemisphere Region’s (IPPF/WHR) Survey of Provider Knowledge, Attitudes and Practices (KAP): This face-to-face interview is designed for administration to women‘s health care providers. It focuses on providers‘ knowledge, attitudes and practices concerning violence in the lives of their patients. There are approximately 80 questions (most close-ended), that cover a range of topics, including: whether, how often and when providers have discussed violence with clients; what providers perceive of as barriers to screening; what providers do when they identify a client who has experienced violence; attitudes toward women who experience violence; knowledge about the consequences of gender-based violence; and the types of training providers have received in the past. Available in English and Spanish.
Forensic and Medical Care Following Sexual Assault Service Education Programme Evaluation Questionnaire: This questionnaire is designed to assess medical personnel‘s knowledge and satisfaction concerning their abilities to treat sexual assault patients, and includes questions such as, how would you rate your ability in forensic evidence collection? It can be self-administered or used as an interview guide. |
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Qualitative, Participatory Methods |
Qualitative methods offer insight into providers’ knowledge, attitudes and practices; and offer insight into institutional practices and norms, as well as group dynamics and work flow. |
Qualitative methods are various and might include focus group discussions, open-ended stories, mapping, role plays, Venn diagrams, etc.
Twubakane GBV/PREVENTING MOTHER TO CHILD TRANSMISSION (PMTCT) Readiness Assessment Toolkit: Focus Group Guides. The guides for clients, service providers and the community are available in English and French. See the section on qualitative methods in the Monitoring and Evaluation module for ideas and examples of what can be used. |
3b. Step Two: Provide staff sensitization and training.
After reviewing the outcomes of the KAP staff assessments, facilities can determine how best to offer sensitization and training. Some methods are:
- Holding intensive training workshops for staff with the help of outside experts or institutions;
- Sending selected staff to course or workshops in other organization or universities;
- Hiring new staff with specific expertise in the area of violence against women and girls;
- Arranging for ongoing training and support from individuals or organizations with specific expertise in areas such as psychology or law;
- Distributing written educational information to providers on a regular basis;
- Incorporating the issue of violence against women and girls into other training workshops for health staff
Excerpted from: Bott, S., Guedes, A., Guezmes, A. and Claramunt, C., 2004. Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals. NY, NY: International Planned Parenthood Federation: Western Hemisphere Region, p.79. Available in English and Spanish.
- When providing staff sensitization and training, it is important to bear in mind that some staff are likely to have experienced violence themselves and/or perpetrated violence. Facilitators must be trained to anticipate and address personal issues that may come up during trainings. At minimum, emotional support should be available to training participants who request it during or after the training.
- The tables below present some of the key sensitization and training topics and objectives, as well as relevant training tools and other resources. For a review of training materials for health care providers, see the Capacity Project Resource Paper, Gender-Based Violence Training Modules: A Collection and Review of Existing Materials for Training Health Workers.
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SENSITIZATION FOR ALL STAFF |
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Topic |
Key Educational Objectives |
Potential tools |
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Human Rights and International and National Laws |
o Understand basic human rights related to health and violence against women and girls, and learn to apply a human rights perspective in the delivery of health services. o Learn about national laws related to violence against women and girls so that health care providers understand their obligations and women and girls can be informed of their legal rights.
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A Human Rights-Based Approach to Programming: Practical Information and Training Materials (2010). This manual produced through collaboration between UNFPA and the Harvard School of Public Health, provides step-by-step guidance on how to apply a culturally sensitive, gender-responsive, human rights-based approach to programming in each of UNFPA’s three core areas of work: population and development, reproductive health, and gender. It also covers how to apply such an approach in the context of a humanitarian emergency. An accompanying set of Training Materials are also available for download. Available in English.
Women's Human Rights: A Manual for Education & Action on Domestic Violence and Sexual Assault (2003). This set of training materials, by Women’s Rights Network, is a training manual for human rights advocates. The manual aims to raise awareness of domestic violence and sexual assault as human rights abuses; enhance the leadership skills of anti-violence activists; and mobilize advocates to implement human rights strategies on violence against women within the United States. The training material involves a combination of lecture, video, and interactive group exercises, and covers reflective and action planning around use of human rights strategies to address violence against women in communities. Available in English.
See also the entire module on legislation in English, French and Spanish. |
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Gender & Social and Cultural Context |
o Understand basic gender issues, including how power inequalities in intimate relationships and in the communities make women and girls vulnerable to violence.
o Understand the cultural factors of vulnerability to violence within the context in which health providers are working. Examples in individual-level factors might be alcohol abuse, intergenerational sex, substance abuse; community-level factors might include extreme poverty, patriarchal norms, etc. (Hainsworth & Zilhão, 2009) Note: Training information should be based on existing research into attitudes on violence against women and girls, or if necessary, on focus groups with community members in order to understand community norms.
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Oxfam Gender Training Manual (1994), is a comprehensive training resource that walks the reader through the training process with accompanying materials, including on: introductions, expectations, sharing experiences, developing consensus, building gender awareness and self-awareness (for both women and men), gender roles, women in the world, gender and development, gender sensitive appraisal and planning, gender and global issues, working with women and men, communicating gender, strategies for change and evaluation. It can be read online from Google Books or is available for purchase from the Oxfam site. Gender, HIV and Human Rights: A Training Manual (2000). This manual developed by UNIFEM is a valuable resource for community-based AIDS workers. The training manual consists of an Introduction; Section I on the challenges of the HIV/AIDS epidemic in the gender and human rights context; Section II on gender concerns in HIV and development; Section III on a human rights approach to HIV/AIDS; Section IV on learning from the workshops; and Section V, an Appendix of questionnaires and helpful websites.
Gender or Sex: Who Cares? (2001). This resource pack published by Ipas and Health and Development Networks includes a manual, curriculum cards and overhead transparencies/handouts, provides an introduction to the topic of gender and sexual and reproductive health. While the resource pack focuses on youth, its participatory tools can be used with a variety of audiences. Available in English and Spanish.
Inner Spaces Outer Faces Initiative Toolkit: Tools for Learning and Action on Gender and Sexuality (2007). This resource, by Cooperative for Assistance and Relief Everywhere, Inc. (CARE) and International Center for Research on Women (ICRW), is for development and health programme staff. The toolkit is a compilation of training, reflection and monitoring activities for programme staff to identify, explore, and challenge social constructions of gender and sexuality in their own lives and those of their partners, in programme interventions, and within their organizations. Available in English. |
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Basic Engagement Skills |
o Know how to provide support and refrain from blaming the victim. Health staff should learn to identify and reject stigmatizing attitudes regarding women’s experience of violence, and counter any norms that accept violence as deserved or even desired, such as “women enjoy punishment.” (Kim and Motsei, 2002) o Learn key messages about to deliver to clients based on human rights principles, i.e. right to live free from violence, so that violence is never justified and never “their fault,” right to refuse sex, etc. o Build skills to face highly emotional issues with empathy and understanding. Learn to accept women’s and girls’ emotional reactions to violence and reassure the survivors that these emotions are normal and justified.
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Communication Skills in Working with Survivors of Gender-Based Violence (2004). This training manual, developed by Family Health International (FHI), the RHRC Consortium, and the International Rescue Committee (IRC) for service providers attending to gender-based-violence (GBV) survivors. The manual includes a detailed 5-day communication skills training of trainers curriculum, with materials, agendas and handouts that may be used by participants to conduct future training. The manual covers the basics of GBV, engagement strategies for working with GBV survivors, service provider responsibilities, community referrals, methods to support service providers, and the evaluation process. Available in English.
Caring for Survivors Training Manual (2010). This manual developed by UNICEF has two parts. Part One of this series of training modules focuses on how multisectoral actors can engage with survivors in a supportive and ethical way. The manual is based on World Health Organization Guidelines. Available in English.
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Basic responsibilities of health sector staff |
o Recognize the importance of the health sector in providing care to survivors o Understand the health impacts of various types of violence against women and girls o Understand the roles of different health staff in providing care o Understand the basic models for addressing violence against women within the health sector. |
Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals: Module on Gender-Based Violence (2005). This set of training materials, by the World Health Organization, is for improving the awareness, knowledge and skills of health professionals around gender-based violence (GBV). The module provides general information on GBV and the role of professionals and the health care system in preventing and responding to GBV. The module also includes examples of good practice at the health facility, community and policy levels, facilitation notes and various tools, resources, and references. Available in English.
Ensuring Privacy and Confidentiality in Reproductive Health Services: A Training Module and Guide for Service Providers (2003), PATH and Global Health Council. Manual contains tools, resources and guidelines on the role of health care workers in addressing violence; guidance to help health workers and managers set up programmes; and tools for assessment, monitoring and evaluation and screening. Available in English. |
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SPECIALIZED TRAINING FOR SELECT STAFF |
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Topic |
Key Educational Objectives |
Illustrative Tools |
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Medical Management of Sexual Assault |
Health providers should learn how to:
Relevant staff also should receive additional specific training in medico-legal examination in order to:
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Caring for Survivors Training Manual (2010). This manual developed by UNICEF has two parts. Part Two of the manual addresses medical interventions for sexual assault survivors and is based on World Health Organization Guidelines. Available in English.
Guidelines for Medico-legal Care for Victims of Sexual Violence (2003). This set of guidelines, by the World Health Organization, is intended for health care professionals and health policy-makers. The guidelines provide professionals with relevant knowledge and skills for the management of sexual violence victims; guidance on developing services and standards for health care and forensic services; and include a sample consultation form. The guidelines may be used for reference, planning health services or policies, as training material, and may be adapted as relevant. Available in English. Clinical Management of Rape Survivors: Developing Protocols for Use with Refugees and Internally Displaced Persons (2004). This set of training materials developed by the World Health Organization and the United Nations High Commission for Refugees, is intended for use by health care providers and trainers of health care providers. The manual desribes best practices in clinical management of rape survivors (women, men and children) in emergency situations to guide the development of protocols, planning care services or training. It explains how to perform a thorough physical examination, record the findings and provide medical care to a sexual abuse survivor. Available in English, French and Arabic. Clinical Care for Sexual Assault Survivors, (2009). This training tool developed by the International Rescue Committee is based on international standards and is aimed at improving the clinical care of sexual assault survivors in low resource settings. Available in English.
Woman-Centered Abortion Care: Reference Manual (2007). This manual published by Ipas is for healthcare personnel including sexual- and reproductive-health clinicians, trainers, managers, educators, social workers, outreach workers and others. The reference may accompany abortion-care training or serve as a learner resource and should be used by trained clinicians with the accompanying Woman-Centered Abortion Care: Trainer's Manual. The manual is organized into two sections that provide guidance on quality of care for women seeking abortion services and technical information for clinical providers or abortion services. Available in English.
For additional tools, search the database.
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Screening and Case Management for Domestic Violence |
o Practice using a culturally adapted screening tool, preferably through role plays and other participatory methods. o Address any injuries or reproductive health problems o Know how to conduct safety assessments o Provide emergency support as needed and referrals to shelters and other care.
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Family Violence Nursing Curriculum (2004). This curriculum developed by the Minnesota Center Against Violence and Abuse, USA provides nursing faculty with essential curricular information to develop competence in preventing, assessing and responding to family violence across the lifespan. Sections cover the scope of the problem, definitions, dynamics, health care implications, integrating into routine assessment, interventions, legal and ethical issues and prevention. Available in English.
Responding to Domestic Abuse: A Handbook for Health Professionals (2005). This handbook developed by the Department of Health, United Kingdom gives practical guidance to health care professionals on how to work with patients whom may have experience or are experiencing domestic abuse. As well as discussing support for abused women, the handbook covers the basic information that health care professionals need to know to respond effectively to children who have experienced or are experiencing domestic abuse. Available in English.
Family Violence Prevention Fund Technical Tools and Materials. These include: clinical practice recommendations for adult and child health settings; an electronic business case tool for health institutions seeking to create comprehensive domestic violence programmes; papers on health privacy principles that protect victims, coding and documentation strategies, and more; screening and response training videos; comprehensive resource and training manuals; clinical reference tools; and patient and public education materials. All materials are available in English.
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Counselling/ Psycho-social Support for Survivors |
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Counseling Guidelines on Domestic Violence (2001). This guide, developed by CIDA and the Southern Africa AIDS Training Programme is for professional and volunteer counselors and other service providers with limited counselling experience in the context of HIV. Part of a series of counselling booklets, the guidelines are based on the experience of domestic violence counsellors from Southern Africa. The guidelines cover issues including: an overview of domestic violence, its link with sexually transmitted diseases and HIV, the nature of effective counselling generally, counselling domestic violence survivors, and survivors living with AIDS, as well as a summary of the opportunities and consequences for action against domestic violence. Available in English. Les violences basées sur le genre: Manuel de formation à l’attention des écoutantes du réseau Anaruz (2006). This guide developed by the Anaruz Network in Morocco is intended for social workers and individuals working in counseling centres. Available in French.
Trainer’s Manual for Rape Trauma Counselors in Kenya, Liverpool VCT (2006) developed by the Kenyan Ministry of Health, United Nations Population Fund and Liverpool VCT is for trainers working with counsellors and other health care providers delivering HIV services. The manual provides guidance for facilitating a counselling programme comprising three modules including practice with skills and counselling simulations. The manual includes a sample training agenda, course purpose and objectives, overview of different topics, methods and assessment tools. Available in English.
Asian Women, Domestic Violence and Mental Health A Toolkit for Health Professionals (2009). This toolkit was developed by the Department of Health in the United Kingdom to guide health care workers in providing contextually appropriate counseling services to South Asian populations. Available in English.
The Power to Change: How to set up and run support groups for victims and survivors of domestic violence (2008). This manual was produced by NANE, AMCV, Associatione Artemisia, NGO Women's Shelter, and Women's Aid Federation of England as participating organizations of the Daphne Project. It outlines key considerations required for establishing and running support groups for survivors of domestic violence, including three possible models that can be used as a basis of running such groups. Available in English, Estonian, Hungarian, Italian, Portuguese and Serbian. |
For additional manuals, guides and trainings in various languages, search the tools database.
3c. Step Three: Provide on-going supervision and support to specialized staff.
- Working with survivors of violence can be challenging for health care providers in many ways. It requires that health care providers use a wide range of clinical skills, for which they may not have received extensive medical training. In addition, listening compassionately to and supporting survivors often requires that health care providers step out of their ‘comfort zone’ of patient engagement. This may be particularly challenging for providers who have themselves been exposed to violence. It also means that health care providers are continuously confronted with stories of violence, which may over time can lead to accumulated levels of stress in the provider, and ultimately to ‘vicarious trauma’ and/or ‘burn out.’
- Vicarious trauma is a term used to describe a situation in which a provider experiences trauma symptoms similar to the original victim after hearing about the victim’s experiences with abuse. Professionals who experience vicarious trauma may show signs of exaggerated startle response, hyper vigilance, nightmares, and intrusive thoughts although they have not experienced a trauma personally.
- Over time, vicarious trauma may lead to burn out, or emotional exhaustion from working with survivors. The physical warning signs of burnout can include headaches, fatigue, lowered immune function, and irritability. A clinician experiencing burnout may begin to lose interest in the welfare of clients, be unable to empathize or feel compassion for clients, and may even begin to feel aversion toward the client.
- As a result of these challenges, health care providers working with abused women and girls should have access to a variety of strategies to reduce stress, including teamwork, satisfactory labour conditions and structures, continuing education, psychological care and preventive vacations.
- Health care providers should also have access to on-going professional supervision. Supervision is a key strategy for ensuring that service providers are working optimally and are using self-reflection and communication to manage the personal and professional challenges of their work. Professional supervision has the following aims:
- To provide service providers with the opportunity to discuss their interaction with survivors to ensure quality of service to clients
- To provide service providers an opportunity to share their experiences, reflect on their work, and solicit support
- To ensure that service providers are maintaining professional distance and are not becoming emotionally overwhelmed.
- Methods for professional supervision might include:
- Individual supervision: This is a process by which as supervising professional reviews cases with the service provider, through verbal discussion and review of interview notes. The supervising professional is tasked with the responsibility of helping the service provider utilize techniques that meet the needs of the survivors while also helping the service provider to maintain professional distance. Individual supervision is also useful in helping the supervising professional to identify any personal issues that the provider may have that may affect their capacity to work with survivors (i.e. personal exposure to violence) and provide referrals for appropriate care.
- Case conferences: Case conferences are an opportunity for a service provider to present to colleagues in a structured format any specific challenges that the service provider may have experienced working with a particular survivor. The goal of a case conference is to seek the professional insights and opinions of colleagues, especially those colleagues with extensive experience or special expertise.
- Peer supervision: Peer supervision is more involved than case conferences, and provides service providers the opportunity to talk with one another about their work, and share experiences and challenges. Peer supervision is an opportunity for peers to exchange strategies for overcoming challenges. Peer supervision also helps to promote cohesion among service providers.
- Peer support groups: Peer support groups are the most informal of all types of supervision. They are designed to provide a way for service providers to talk among themselves about their feelings regarding their work, and to offer each other mutual support. Peer support groups do not include supervisors (who should have their own peer support group). Peer support groups focus more on the emotional needs of the service provider than on case management. It is important that supervisors encourage peer support groups by allotting regular time for co-workers to gather informally during work hours. (Adapted from IRC and FHI, 2000. “Communication Skills in Working with Survivors of Gender-based Violence: A Five-day Training Manual”, Day 4.)
Lesson learned: When PLAFAM, IPPF/WHR’s association in Venezuela, began screening its clients systematically for gender-based violence, an unexpected challenge surfaced: the emotional toll on providers that resulted from dealing with gender-based violence on a daily basis. After intense sensitization and training, the providers were prepared to listen sympathetically to their clients’ stories and to offer them counselling and/or referrals, but they were not prepared to deal with how hearing about violence would affect them. PLAFAM quickly recognized that providers, too, need an outlet to talk about the situation that they confront in order to reduce the emotional stress and potential for burnout. Starting monthly support groups for providers not only created this outlet, but also gave the providers a chance to discuss problematic professional issues that they encountered in working with victims of gender-based violence.
Excerpted from: Bott, S., Guedes, A., Guezmes, A. and Claramunt, C., 2004. Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals. NY, NY: International Planned Parenthood Federation: Western Hemisphere Region, p. 135. Available in English and Spanish.
Illustrative Tools:
Caring for Survivors Training Manual, Module 8 (United Nations Children’s Fund). 2010. Available in English.
Communication Skills in Working with Survivors of Gender-based Violence: A Five-day Training Manual, Day 4 (International Rescue Committee and Family Health International, 2000). Available in English.
Helping Ourselves to Help Others: Self-care Guide for Those Who Work in the Field of Family Violence (Claramunt/PAHO/WHO,1999). Available in English.
Insights into the Concept of Stress (Bryce, P./PAHO, 2001). This resource, developed by the Program on Emergency Preparedness and Disaster Relief of the Pan American Health Organization, provides disaster response personnel with basic knowledge and skills on the principles of stress and critical incident stress management. As a companion to the Stress Management in Disasters (SMID) book, the resources assist emergency response personnel to recognize stress and manage their emotional responses to traumatic situations, such as disasters. Although the book was developed for emergency and disaster response personnel, the principles may be modified and applied to prevent and address traumatic stress within the broader community, including with children and adolescents. Available in English.
Additional Resources:
Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals (Bott, S., Guedes, A., Guezmes, A. and Claramunt/International Planned Parenthood Federation: Western Hemisphere Region, 2004). Available in English and Spanish.
The National Online Resource Center on Violence Against Women has several resources related to supporting staff who work with survivors, including:
- Guidebook on Vicarious Trauma: Recommended Solutions for Anti-violence Workers, Jan I. Richardson, Centre for Research on Violence Against Women and Children, National Clearinghouse on Family Violence (2001). Attempts to recognize the unique experiences of anti-violence workers in Canada, promoting individual, equity, and organizational supports. This guidebook explores the response to vicarious trauma within certain communities and cultural groups.
- Organizational Prevention of Vicarious Trauma, Holly Bell, Shanti Kulkarni, and Lisa Dalton, Families and Society: The Journal of Contemporary Human Services (October-December 2003). This article discusses the importance of work environment in the development of vicarious trauma problems for domestic and sexual violence workers.
- Trauma, Post-Traumatic Stress Disorder and Secondary Trauma, Barbara Whitmer, Education Wife Assault (2001). This article clearly defines trauma, post-traumatic stress disorder (PTSD), and secondary trauma and how secondary trauma affects those who work with traumatized clients.
- Vicarious Trauma: Bearing Witness to Another's Trauma, Terri S. Nelson, gives a brief discussion about what vicarious trauma is and how important it is that advocates/counselors be aware of it, recognize the warning signs, and take care of ourselves.