By Deirdre Walsh, BA, M Psych Sc, Reg Psychol P soc I.
When invited to write this article I was asked to consider if therapy with victims of sexual abuse is different from other psychotherapies, a question which I have often put to myself over the past number of years. I have argued both sides of the case in my head, and willed that my conclusion should be “no” in order not to add to any pool of resistance or fear that still pervades working with sexual abuse, but I am forced in the end to conclude that there are differences in working therapeutically with sexual abuse. A respect for and honesty about these differences may only enhance and deepen the quality of work done with victims of abuse. To elucidate these differences I propose that we consider three issues:
a) What lies within the client who has been a victim of sexual abuse?
b) What is required and demanded of a therapist working with people who have been abused?
c) What is needed therapeutically to assist someone to recover from and heal the experience of abuse?
What lies within the client who has been a victim of sexual abuse?
A woman sat in my room recently and after two years in psychotherapy she bowed her head and said very quietly, with tears falling onto her lap, “something very wrong has been done to me”. I stayed with her in silence, there were no words to meet it, it was her moment of realization and externalization. The pain had finally broken through. Something very wrong has been done to me, and at a time when I was at my most vulnerable, my most defenceless, my most formative.
I believe that the pain of having been sexually abused is a deep and profound pain, that is experienced on a physical, emotional and spiritual level. It touches a person’s core, it is beyond words. The violation of a person’s body, of their innocence, of their sexuality, is bad enough, the abuse of their emotional integrity, the distortions, the lies, the manipulations, add a deeper level of damage and pain, and for many victims of sexual abuse it feels like a defilement of their spirit has taken place that something in their essence has been deeply wounded and is in need of healing. The deep internalization of guilt and shame that so often accompanies abuse further complicates the experience, “I am bad”. In fact there is often no sense of “I am”, but rather “I am abuse”. It is the separation of abuse from self that becomes one of the cornerstones of therapy, because when the experience of abuse is ongoing, a person’s personality development has been inextricably bound up with same.
It is now recognized that the client who has been sexually abused is presenting with a post traumatic stress disorder. This traumatic neurosis is the result of being overwhelmed by an experience beyond the child’s capacity to handle. After an initial response of fear or terror, emotional numbing and denial set in, allowing the child to disassociate and thus endure the abuse. The disassociation is at a physical, emotional or cognitive level, and as we know from war victims, is a highly adaptive way of coping with traumatic events usually beyond the range of human experience.
The characteristic symptoms of post traumatic stress disorder are : (Meiselman, 1990)
1. Re-experiencing of the trauma (nightmares, flashbacks, dissociative states)
2. Reduced responsiveness to external world (psychic numbing, detachment)
3. Other associated symptoms (anxiety, depression, poor concentration, insomnia, etc.).
It is usually at the point when the victim’s denial and emotional numbing no longer work, when the trauma of the abuse begins to leak into the person’s life at a cognitive, emotional or behaviour level, that they seek help.
The context of abuse
To apply a post traumatic stress model alone to sexual abuse is however neither adequate nor appropriate. The context within which the abuse is experienced the family atmosphere, the complexity of relationships, the distortion of roles leave as deep a mark on the development of the child as the trauma of the physical experience. The child who is abused is denied her/his right to childhood, they are in an adult sexual role long before their years. They may be experiencing role reversal – the “little mother syndrome”. They carry the burden of being the “keeper of the secret”, and of living the lie the “everything is normal” (Poston & Lison, 1989)
The complexity of the damage of abuse needs to be recognized and responded to by therapists. In my work over the years I have come to recognize six core effects of sexual abuse.
- An enduring post traumatic stress disorder.
- Deep damage to ability to trust (self, others, world).
- Acute damage to self-esteem.
- Deep emotional pain (sometimes masked).
- Damage to sexuality.
- Damage of autonomy.
These core effects lead to a way of living in the world that embraces a whole range of dysfunctional belief systems, behavioural patterns and symptomatology.
The adult legacy of sexual abuse is complicated and varied and is rooted in a need to protect oneself at all costs from more pain. It is only when the protective defences are no longer working that a victim will seek help, when life has become too painful to continue to negotiate. Thus we are faced with a person who has already endured profound suffering and who has lost so much, and as a therapist you know that the only way back to “self and a resolving of the trauma is through a painful re-experiencing of the trauma and a gradual re-integration of the personality. Each of the core effects of abuse needs to be attended to. This is a slow and intricate process not without its rewards, but I think that the sexually abused client presents with a particular quality of experience that is not mirrored in other client populations.
What is required and demanded of a therapist working with sexual abuse?
The incest taboo has pervaded almost all of our cultures for many centuries now. It is almost universal in its application with regard to father-daughter, mother-son, brother-sister union, greater variation exists with regard to extended family, among cultures. The only two recognized exceptions are royal incest, where members of royal families were encouraged to marry each other, and “magical” incest particularly in the context of satanic rituals (Meiselman 1991). The existence of the incest taboo has relevance to therapists because we must recognize our own emotional and defensive reactions to sexual abuse. We must meet our own sense of horror, or revulsion. We must also seek out the ways in which we deny the reality of abuse – sometimes the denials are subtle and covert. Working with sexual abuse asks of therapists that they believe the unbelievable, think the unthinkable and learn to leave aside the comfort of the illusions that we all want to hold onto about our world and our humanity. This puts a great personal demand on the therapist because it requires a confrontation of self at a very deep level, a willingness to be able to listen to deeply painful material, to realize that there is nothing that one human being will not do to another.
The quality of listening
The quality of this listening is another essential cornerstone of therapy. People who have been abused are fragile in their ability to trust and strong in their expectation of being rejected. Thus the smallest flicker of a muscle will tell them you are not ready to hear, you must be protected or worse, that you hear but do not believe. This failure on the part of the therapist then consigns the client to a deeper abyss of shame and self-rejection. The “handing over” of the abuse is essential to a client because anything held back will block their recovery. This means that the therapists must have a deep capacity to be open to receiving whatever the client needs to let go of. Moreover the humanity of the client and therapist must be allowed to meet. I believe that this immediately begs two questions of therapists.
1. How have you worked on your own blocks and fears?
2. What kind of support is there for you now?
It is essential that anyone working with victims of sexual abuse would have experienced therapy for themselves. I don’t believe that we have the right to ask clients to go to places within themselves that we have not gone within ourselves. The quality and depth of our own personal work will determine and form the quality and depth of our work with clients.
For any therapist working with sexual abuse, there are in my opinion certain basic essential requirements.
1. An openness and willingness to challenge and confront personal blocks.
2. A commitment to personal work.
3. An ability to hear the awfulness of abuse.
4. An ability to tolerate and stay with great emotional pain.
5. An openness about sexuality.
6. A theoretical understanding of the complexity of abuse.
7. A therapeutic model that is sufficiently inclusive of the client’s needs.
8. Adequate support.
Over and above all of this, any therapist working with sexual abuse will, from time to time be forced to confront at a personal level, issues regarding humanity a nd the nature of humanity. This deeper existential questioning may be a painful and personally demanding experience.
What is needed therapeutically to assist someone to recover from and heal the experience of abuse?
The answer to this question is a complex one, and the danger of the written word is that it becomes fossilized. Over the years I have found that my own therapeutic response has developed and changed organically, and evolves and is refined by new experience and new material.
At the core is the therapeutic relationship, one where the gradual special bond between client and therapist allows a foundation of trust and care to develop, within which it becomes safe for the client to face the truth of the abuse. Within this relationship trust can be tested by the client, and the experience of being cared for allows a slow healing of self-esteem. There also needs to be limits and boundaries to this relationship, in order to provide safety for client and therapist alike. The issue of power needs to be attended to, as any abuse of power on the part of the therapist will lead to a re-victimization experience for the client; the client needs to be encouraged to take control of their therapy in a positive wholesome way. In working with people who have been abused, a framing of the normality and appropriateness of their responses to the abuse (even their symptomatology) can often bring great relief and take away the awful fear of being mad or going mad.
Recovery and Healing
Given that the therapeutic relationship is primary, within that relationship certain things need to happen for the client in order to recover from and heal the abuse.
1. A Healing Catharsis of the Trauma
The client must be facilitated to allow the repressed material to re-emerge. This can often happen as a painful re-experience of the abuse. Memories emerge in ordinary consciousness in the form of flashbacks, dreams or dissociative states. The memories may be visual or may come as a bodily re-experiencing of the abuse. Repressed emotions also begin to flood back – fear, pain, anger, sadness, despair, all need to be experienced and expressed.
Strong support is needed by the client during these experiences as they regress to childlike states and experience powerful overwhelming changes within themselves that often bring within them the fear of going insane. The therapist needs to have a knowledge of regression work and cathartic work so that she/he can “hold” the client with firmness and support through this work.
2. Gradual Examination of Relationships
The second essential task in working with victims of sexual abuse is the gradual examination of relationships within the family, and of illusions or assumptions that lie behind them. This also brings up issues of patterns in adult relationships, issues to do with trust, fear of people, fear of intimacy. This is often the time where group work can be invaluable as it allows clients to test trust at deeper levels and to recognize common patterns and begin to change them. Herein also lies the challenge of moving away from a victim position to live in the world as a healed person with a deep responsibility for self. Letting go of old patterns can be painfully slow, and often the desire for “freedom” brings up fear, resistance and a fear of failure.
3. Re-Integration of Sexuality
For a long time it was my belief that if all the rest of the work was done, any damage to sexuality would heal spontaneously; sadly, not so. I now see it as an essential part of the healing of sexual abuse that sexuality be focused on in a very particular way toward the end of therapy. This is far more fruitfully done in the context of a small (same sex) group, of perhaps six to eight clients. Sexual education is often essential as there can be great ignorance or resistance to information on the part of abuse victims. Basic education, an exploration of sexual topics, a reclaiming of the body, fun, nurturing and self care are all part of this focus. An openness to one’s individual sexuality is essential before any relationship issues can be addressed.
Broad range of therapeutic skills
So in order to work with clients who have been sexually abused, I think it is important to have a broad range of therapeutic skills and a holistic eclectic approach. To work at the cognitive, behavioural, emotional and psychodynamic levels seems essential as abuse affects people at each of these levels.
Offering one narrow therapeutic approach, while gains may be made, often fails to move the client to recovery, just as treating symptomatology fails to move people to recovery. I think that a grounding in the basic principles of cognitive therapy, behaviour therapy and gestalt therapy, along with body work experience is essential. A knowledge of psychodynamic material and the workings of the unconscious is important. And beyond that, any experience in family and marital therapy, in art therapy, group processes, psychodrama, etc, is useful and enlightening.
For the first time in history, the reality and extent of sexual abuse is being recognized. Previous attempts to do so have failed or been thwarted. With the sophisticated communication systems that we now have, it looks as if this time sexual abuse will not be consigned to secrecy again. It seems to be the task of therapists to help heal such pain. Not all therapists will choose to work in this area. Those who do need on-going dialogue, information, training and support to do our job in better and better ways. People who have been abused have everything to teach us, if we are willing to learn.
There is some anxiety in me that in five years’ time I will read this article and refute half of it because of new learning, but today these are my thoughts.
Meiselman, Karen: Resolving the Trauma of Incest, 1990
Poston, C. And Lison, K.: Reclaiming Our Lives, 1989.
Deirdre Walsh is a clinical psychologist and psychotherapist. She worked for five years in the Dublin Rape Crisis Centre and for the latter two was clinical director of the therapy programme. She has worked extensively with adult victims of child sexual abuse and has also been involved in the training of professionals to work with abuse. She is also co-author of Surviving Sexual Abuse, Attic Press, 1988. She is currently in private practice in Avalon Therapy Centre.