Evaluation of the NT MOS projects
Service focus
Up to Closing the Gap: Northern Territory
There are mixed views about whether the original MOS or current MOS Plus focus is the most appropriate.
Key stakeholders interviewed, including government service providers, outreach service providers, peak bodies and Aboriginal health service agencies were almost unanimous in their view that the service focus should remain child sexual assault.
The area of sexual assault was seen as a significant need in its own right. Others saw this specialist focus in an outreach service as being clearly delineated for community and local agencies, especially if it offered consultancy advice to local service providers. The concern expressed was that other areas of counselling, perhaps more 'accessible' in terms of client engagement, would become the focus of the service - to the detriment of the challenging and sensitive area of child sexual assault counselling.
However, there were some central and outreach service providers who supported the expansion of the scope of the service. Some saw it as an opportunity for greater flexibility in terms of service response, as disclosure of child sexual assault is extremely sensitive. The view expressed was that people generally will not come forward about sexual assault. Children and families may establish trust with the service provider through engagement in relation to another 'presenting' issue, before feeling safe to disclose.
Others saw the experience of abuse as part of a 'continuum' of experience, and focussing on trauma related to only one form of abuse creates artificial divisions. Others focused on the therapeutic aspects of the service:
"...There is a tendency to set services up to separate various forms of abuse. From a clinical point of view, you would say the effect is the same because the psychological harm is the ongoing effect from both types of abuse. The service should be for children abused in any way...Most extreme acts of neglect (rather than mere acts of omission) should be seen in the same category...." (MOS Expert Reference Group member)
In communities, there were rather more mixed views as to the most appropriate focus of the service.
Local organisations, where there was already some awareness of the MOS Plus services, generally thought it was a service with a sexual assault specialist focus.
Some considered any regional health-related service needed to have a broader social support network focus, as well as a family support investigative function. Others expressed the concern that sexual assault is an extremely sensitive area in communities, often protected by family members - and therefore requiring a specific focus for intervention and engagement.
The 'initial assessment' data of MOS Projects' casework cases shows child sexual assault as by far the most commonly identified underlying cause of trauma for clients referred to the service, over the period of the evaluation. Although child sexual assault, as a per cent of the total underlying causes of trauma, reduced upon the broadening of the service scope to MOS Plus, the number of cases continued to grow.
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In discussions with local community organisations where the MOS Plus service was not known or well understood, most expressed reservations about defining a service as focusing on concepts of child abuse and/or neglect. Many considered that definitions of neglect and abuse are open to perception, and experiences such as 'failure to thrive' may not be related to not being looked after properly. Terminology such as 'counselling', trauma', and 'abuse' were not considered to necessarily be understood in community, and using more common words such as 'safe', healing' and 'humbugging' would be more appropriate.
Others interviewed spoke about systemic issues in relation to neglect and trauma, and the implications for a therapeutic counselling service, particularly one with a focus for children and young people under 18 years. A number of stakeholders interviewed spoke of institutionalised trauma and the experience of violence over many generations, and the assumption that people have the education and skills to address the causes and impacts. A number of stakeholders specifically spoke of the lack of parenting skills, and that people assume they get this mentoring from the previous generation.
In community, 'trauma' as a concept was understood. Community members, and many of the local organisations, spoke about the level of general trauma prevalent in communities, and the need for counselling and support services. This was not necessarily focused on trauma associated with child abuse and/or neglect.
The incidence of death (often by violent means) and Sorry Business in communities was raised in a number of the communities visited. The high incidence of suicide (usually adolescents and young men, and by hanging) was raised in two communities; another two communities were mourning the recent deaths of young boys as a result of crocodile attacks; and in another community two children had recently been killed in a car accident. One of the evaluation team's scheduled visit to community was also cancelled due to Sorry Business - a suicide of a young person.
Community members interviewed generally saw the value of a more holistic trauma-focused service for young people, without distinction as to the primary 'cause' of the trauma.
The need was seen for a qualified counsellor, visiting regularly, to support children to recover from the trauma they witness and the trauma experienced. It was considered important to establish what 'trauma' meant for the family in the context of the specific community, and then to develop the therapeutic service model around that understanding.
Finding
There are mixed views about whether the original MOS or current MOS Plus focus is the most appropriate. Many stakeholders expressed concern that the specialist area of child sexual assault counselling will be 'lost' in an expanded service scope. However, the data relating to MOS Projects' casework shows sexual assault as by far the most commonly identified underlying cause of trauma for clients referred to the service, over the period of the evaluation. The number of cases citing sexual abuse has continued to grow in the period following the service scope expansion to MOS Plus. Many stakeholders interviewed spoke of reservations about defining a service as focusing on concepts of child abuse and neglect. Local organisations and community members were supportive of broader counselling and support services addressing trauma in communities.Forensic Medical Examinations
The Forensic Medical Examination (FME) remote servicing component of MOS Plus is still in development, and is the subject of a separate internal review process. As part of the evaluation of the MOS Projects, where feasible and appropriate, stakeholders were asked about the remote FME. There were mixed views about the benefits of forensic medical services delivered within the community, rather than at a regional or city facility.One stakeholder interviewed noted that sexual assault has a huge impact upon communities and mobilises a whole range of service responses - and that forensic medical examinations cannot be separated out from those responses.
Many of those interviewed saw the FME as part of a more general medical response and very rarely 'forensic' in terms of purpose. That is, not related to criminal prosecution, and more related to psychosocial issues for the child and the family. It was usually about discussing health matters, treating sexually transmitted infections, and discussing follow up and care, and protective behaviours.
In terms of remote access, many considered the location of the FME should be based on an assessment of what was the most appropriate and culturally appropriate option for the child and the family. Some stakeholders noted that often the family preferred to have the examination 'in town', as: there were often other medical or safety concerns such as: being out of community should the perpetrator be 'hanging around'; and the potential for greater privacy and 'less shame'. It also enabled the family to access other services and shops at the same time.
One stakeholder raised the Patient Assisted Transport Scheme (PATS) as one of the disincentives to the FME being conducted in Darwin, Alice Springs or Tennant Creek. The view expressed was that PATS is not set up for children in these circumstances - the number of family support people to accompany the child is restricted, and that it can take days to travel back to community.
Data on the number and location of Forensic Medical Examinations (FMEs) has not been presented in this report due to privacy concerns related to the small number of examinations that have occurred. It is noted that a separate internal review of FMEs is currently being jointly undertaken by the NT Department of Children and Families and OATSIH.