I have been working with adult survivors of sexual abuse for many years now within my psychotherapy practice. Throughout this time I have been privileged to be a part of many remarkable journeys, remarkable in the determination and spirit of the people dedicated to recovery. The victims of sexual abuse have suffered the fundamental indignities to their spirit, psyche, emotions and body: They have suffered the deepest of injuries. This article is first and foremost a testimony to them, secondly a description and plan on how to work adult survivors of sexual abuse which I hope may give useful suggestions for others that may be embarking on a similar journey. Firstly. I never cease to be amazed at the strength of will and courage of my clients and I feel privileged that they have chosen me to witness their path, and it is in this context that I hope my ideas will be a source of hope and give others practical suggestions for their own particular journey. The effect on people's lives who have been sexually abused are many and far reaching, typically they may show some of the following symptoms.
Panic attacks can make feel as if they are going to faint or cannot breath. They may feel as if their world is going to collapse and they often have no logical reason for their attacks.
There are situations that may arise when something in the present may evoke a memory of the past and it is as if the person has 'rubber banded' back to the experience of the past.
This is a particularly difficult area for adult surviors of sexual abuse as most will find it hard to trust from the heart. Also they may find difficulties maintaining healthy and meaningful relationships. These issues are often what people present when they first attend for therapy, or indeed it is the major problem that they want to change in their lives.
In the area of sexuality many consequences of abuse are reported. Individuals sometimes feel they can never have a sexual relationship again or at least may feel flawed in the area. Some become abusers themselves, playing out their early hurts and traumas on others.
Self image is often very low, as they may believe that there is something wrong with themselves and could often report feeling dirty. Unlovable and worthless. They may sometimes hurt themselves and even believe that they do not have the right to exist.
Dissociation is one of the major defence systems that people who have been abused with use in the service of protection of their inner self. Dissociation is when the person moves psychologically away from the part of themselves so as not to feel the trauma and pain. In the present, this process in its extreme, could become problematic for the individual in maintaining healthy relationships, and may hinder them in getting close to people and expressing their feelings. This is often why adult survivors of sexual abuse sometimes turn to alcohol and or substance abuse in an attempt to block out the emotional memories of the past in order not to feel in the present.
Depression is a turning in on oneself, often associated with feelings of worthlessness and powerlessness. Depression is common in survivors of abuse, they can feel as if they were born in a depressed state and may feel that life is not worth living.
Both these feelings are common in adult survivors of sexual abuse even if they are not in touch with these feelings. Rage in this sense is more likely to be turned inwards, in some cases self mutilation may occur. Often the survivor may feel intense terror and see the world as a scary place.
Grief often internally held in is primarily about the loss of a childhood spoiled forever. This can be overwhelming and the person may feel that they could cry forever. It is a deep reaching sadness which is often held at a physical level as well as an emotional one.
In working with adult survivors the therapist needs to come from a caring, non- threatening and a non-damaging position right from the start of therapy. This type of relationship will go a long way towards 'normalising' the client's reality. I see seven distinct stages in the process when working alongside survivors:
It must be remembered that I do not necessarily see the seven stages as linear, the therapist and client may move in and out of each stage as the therapeutic relationship demands.
The first stage and perhaps the most important is the establishment of the trusting relationship with client. This is crucial as the client needs to feel OK and validated by the therapist. It is in this initial stage where the client begins to tell their story, and it is the task o the therapist to listen to the experiences of the client. The therapist also needs, at this stage, to emphasise the protective structures for the client in promoting a safe supportive climate for therapy. This protection has to be internal and external. The therapist's task is to facilitate the person in protecting themselves from their internal ogres and demons. The therapist may do this by giving permissions to the client and allowing them, perhaps for the first time, to be themselves in a powerful way. This process takes time as they may have lost sight of their real self. It is only in a protected , safe place that the client will feel that they can, bit by bit, allow themselves to experience fully what it is like to be in touch with their real self The therapist also has to protect the client in the current environment (real. or imagined) by establishing a safe therapeutic environment. It is only then that the client will feel free enough to progress on the path of healing.
The second stage for the client in this process is one where the individual will, with the help of the therapist, begin to explore their past. The therapist must remember when working within this stage that it takes great courage for the client to go back to what must have been a nightmare for them! To invite anyone back into their own personal nightmare must not be taken lightly. Indeed, there is a fine dividing line between re-experiencing their trauma and re-living it.
Re-experiencing the trauma can be seen as a positive experience for the client in the sense that though they may experience a flavour of their earlier abuse, this time it will be different because now with the therapist, they will have a protective, caring 'other' who will stand up for them in the services of the early child. Re-living the experience would mean a negative re-traumatisation for the client where the person repeats for themselves their early abuse, perhaps making the therapist the abuser in the process. This process may happen unconsciously without either the therapist or the client being aware of this until they are many sessions down the line.
A recent example of this was when a therapist reported to me that he could not understand the anger that his client seemed to have towards him. After further discussion and supervision it seemed to him that the relationship had changed since he had done a "fine moving piece of work" with his client, (the client was recalling some early abuse by her father). The therapist was confused by his- client's anger especially as after this piece of therapy she had allowed him to 'hug' her for the first time. However it was this hug that the client, within the transferentail process, experienced as being a reinforcement of the earlier abuse, and consequently her maintaining of her not OK position in life.
It is in this early stage of explaining the person's past that the client may have 'flashbacks' and recall memories that she had 'forgotten' from her childhood. It is here that the protection structures may now have to be emphasised more and increased contact with the therapist may be needed, i.e. seeing the therapist twice a week, or options to join a psychotherapy group where the more experienced group member would be available during this time for providing a safe, protective place for the client to be.
During this process of exploring the past with the client, the client may move into what could be called the third stage emergency phase; this is where the person may be flooded with emotions. It is imperative that they are dealt with and worked through and that the client makes the connections with the past to the present and vice-versa.
In my experience rage and sadness are the most common feelings at the time, so the therapist must. decide, for example to teach the client methods of releasing rage in a safe way, so that they can deal with them amid move on instead of feeling stuck with the feeling. Rage, as any feeling can be a here and now feeling to what happened there and then.
After working through the feelings which have been connected to the past the client often feels a sense of grief for the part of their childhood which they never experienced which is the fourth stage, they need to be encouraged to feel their feelings in order that they can move on to a recovery instead of stagnation.
The fifth stage in the recovery process for the client is for them to become aware of the early decisions that they made about themselves and life in response to their abuse The early decisions, although appropriate at the time, may be what is stopping them obtaining what they healthy abilities or qualities that they may wish to acquire, want in the here and now.
Such early decision in response to the abuser or abusers may include:
These early decisions need to be re-decided for the person to be more healthy. Remember that we cannot change the past but we can change our response to it. People can re-decide their early decisions, they can decide to be different and see themselves in a new light. It is important that these early decisions are made to counteract the old decisions and replace them. The therapist needs to invite the client back to the time when the old decisions were made and facilitate them, through therapy, to make a new and healthy decision.
After the redecision stage comes the sixth stage the reintegration stage. Here the client needs to learn how to integrate these new decisions into their life. This may be a difficult and scary time for them, changing a habit of a lifetime may be frightening and challenging, Indeed, implementing new healthy ways of functioning will take time and practice, and will seem unfamiliar and uncomfortable at times.
During this time the person will need the support of their friends and it may be important to them to be in a therapy group to gain support as they try out new ways of being. One of the things that could be incorporated into the persons therapy at this stage could be to encourage the client to identify people who embody the healthy abilities or qualities that they may wish to acquire, and to be someone they admire, even if it is only for a short time, and noticing how this feels.
It must be noted here that this process is not a good idea for clients who use 'splitting' as a major defence system or clients with multiple personality disorder.
The final stage in the recovery is for the person to say good-bye to the hurts and indignities of the past and hello to their present and future. Within this process it is important for the therapist to have encouraged the person to celebrate their victories. Also the primary task for the therapist is one of checking that the client has moved form victimisation to a quality of life which is on of satisfaction and contentment. The emphasis is about completion and moving on, also about recognition of their own achievements. Finally, it is about new recognition that they are loveable and loved by others it is a time for reflection, for both the past and future, with the knowledge that they will always be welcome back to therapy if and when needed.
First published in Cahoots magazine July/Oct 1995
Bob Cooke B.A. PTSTA. PGCE. is the Principle Director of the Manchester Institute
Psychotherapy. He runs a private practice and also a comprehensive training
programme for Transactional Analysis.