by Rachel Somers
As I considered writing an article on the presenting issues facing a therapist when working with an individual who has experienced sexual abuse and addiction, I became aware and was struck by the many factors which can challenge the therapist. I became interested in hearing my colleagues’ and peers’ opinions and their experiences regarding this subject and was struck by the array of reactions to the subject. These included fearful facial expressions; some long silences while pondering the subject, and comments such as “well, you’re not working with the whole person, are you?” As I met these reactions, I wondered what is it about the subject of working with sexual abuse combined with addiction that could possibly provoke such reactions. I was also left with the question of who is it I am actually working with, if it’s not the whole person.
The following article is an account of the presenting issues relating to individuals who are in therapy to process issues of sexual abuse and addiction. It explores the resistance to this type of work, and the gap such resistance can leave. I have outlined the defenses met within the individual and the awareness the therapist needs to work in this area and thus explores the overall difficulties presented when working with an individual who has experienced sexual violence and uses addiction as a coping strategy.
Resistance and Reluctance
I initially became aware of a resistance to working within this field some years ago. I discovered a reluctance within some organisations and even with individual therapists to working with the issue of addiction in conjunction with sexual abuse.
This reluctance came and presented itself in my experience as an addiction counsellor as I attempted to refer clients for therapy regarding sexual abuse. I was met with several similar responses of “the client will have to deal with the addiction before we can see him/her”, or “not until they have finished their treatment”. This restriction created a waiting period for the client who needed to avail of appropriate support services when most vulnerable. Such responses not only highlighted a gap and delay in the level of support available to the client but also encouraged me to question the whys regarding this gap. Surely, an individual, if addicted whether it is to food, sex, heroin, alcohol, etc.., will constantly be dealing with, or in recovery for this addiction for the rest of his/her life. Therefore, how can the individual seek adequate support and therapeutic intervention regarding experiences of sexual abuse when needed?
In my work as a psychotherapist and addiction counsellor, I have found that the issues involved in working with individuals who have had an experience of sexual abuse or violence and who use addiction as a way of coping, can be complicated. The therapist can discover varying additional issues which require a wide range of skills and education. The therapist can become challenged to work in a way which can often conflict with various schools of thought regarding psychotherapy and its process.
A Challenging Approach
Having worked within the field of addiction for 6 years I became aware of the issues which presented themselves when working with an individual. I was struck by the large proportion of clients, initially coping with addiction, but also who had used their addiction as a coping mechanism to relieve the pain of their experience of sexual abuse or/and violence as a child. The basic recovery issues facing the client in recovery for addiction involve behavioural adjustment, self awareness, self identity development, knowledge of addiction and cognitive denial, underlying factors, relapse prevention, stress management, personal goal setting, social development, understanding relationships, assertiveness training, money management and further education. When working with an individual who has experienced sexual abuse one can expect to meet post-traumatic stress, depression, panic attacks, dissociation, obsessive compulsion, impact and distress of the trauma, flashbacks, sleep disturbance, fear, anxiety, terror, loss, relationship issues, social isolation, physical manifestations, eating disorders, suicidal ideation and self harm.
A cognitive, educative and often directive approach is required when working with the individual who is working through addiction. This teaches and encourages the client to explore the defenses and behaviours the individual uses to ‘get what they want’. When observed, these defenses often become evident within sessions and in the therapeutic relationship with the therapist. This transferential experience can be very useful to work with and in my opinion, must be worked with before the “whole person” may become revealed. Addiction can often be the defense strategy used to mask and avoid working through the internalized affects of sexual abuse and sexual violence. Therefore to enter into a therapeutic alliance with the client who has experience of both, means to adopt an often educative and cognitive role toward client work, as well as the humanistic and person-centred approach. This can challenge an entire core belief as to what therapy is and involves.
Mechanisms at Work
It is my belief that the ultimate aim for the individual dealing with sexual abuse and addiction in therapy is to take personal responsibility for the self and the behaviours used to cope with life before any exploration of past experience can occur.
The following is an account of what one may meet as a therapist working with such an individual. These behaviours can seek to withhold the individual from the experience, emotion and thought of sexual abuse as a child or young adult.
Blame is often met when working with clients dealing with addiction and sexual abuse. A lengthy period of time might be spent in this position. While here the client can explore emotions such as frustration, irritation, anger and rage, the potential for the client to become enmeshed in this position is quite high. The client might blame others for their own behaviour, feelings and thoughts. There can be a reluctance in naming and taking responsibility for the self. The focus on “He made me feel”, as opposed to “I feel”, can act as a barrier at times to connection with self and the personal experience. Therefore the therapist must be confident in sensitively challenging this behaviour once the individual begins to present this enmeshment. To not challenge this behaviour facilitates the client to remain in this position and can enable the individual not to take personal responsibility for the self and their own recovery.
To maximize, is a behaviour often used by the individual dealing with addiction and sexual abuse. This behaviour can provide the space and the time for the subject of change and responsibility to become much bigger than is the reality. As long as change is too big and unreachable, then the potential for taking personal responsibility is greatly reduced for the client. The therapist must be capable of bringing this to a state of awareness for the client. By using cognitive awareness, the reality of the ‘now’ must be presented to counteract the client’s often distorted and manipulated perception.
Minimisation is the mechanism which can be used again by the client, to alter the current reality of the client’s situation. Sometimes the addiction and/or abuse can be presented as ‘lesser than’ the reality. As with Maximisation, the therapist needs to explore the reality of the situation with the client. In this work it can be important to explore the reality and challenge the before mentioned distorted perception of the client.
Justification and Rationale
These can be the strategies used by the individual to make the abuse or addiction ’ok’. If the subject is ‘ok’ then it does not need to be explored, expressed or worked through. Therefore change (in the eyes of the client) is not needed. The therapist might be met with remarks such as “It’s not that bad” or “It’s nothing major”. The therapist can sometimes become confused and bewildered by a blizzard of words, ideas and false reasons which can only serve to interfere and prevent the individual from being seen. The damage experienced as a result of sexual abuse can be extensive. Sexual abuse is an intensive form of violation and can lead to the individual feeling objectified. The self can be seen and experienced as an object rather than a person deserving of care and attention. With this the person can take on the shame of their abuser and can develop irrational beliefs of ‘being a bad person’. The therapist might hear statements such as “I will never heal” or “all I’m good for is sex”. These beliefs and behaviours, if facilitated and left unchallenged will only serve to restrict the level of recovery the client is fully capable of achieving.
Denial can be described as an ego defense mechanism that operates unconsciously to resolve emotional conflict and to allay anxiety by refusing to perceive the more unpleasant aspects of external reality. The individual believes their own deceptions and distortions and therefore observes the contrasting opinion of others as false. This suppression of reality can enable the client to avoid personal responsibility. It can be important therefore to inform and educate the client as to the differing mechanisms used to defend the self from the reality of the sexual abuse.
Manipulation can be presented in varying different patterns for the individual and is an effective method whereby the client can ‘get what they want’. Instead of asserting the self in a direct fashion (because the skills may not be there to do so), the therapist might find him/herself manipulated. For e.g. to provide extra sessions, not to challenge, for sessions to be missed, and to allow the boundaries of the session and the relationship to loosen. While I worked in an addiction treatment centre I became aware of a consistent pattern of client’s informing me of how wonderful I was, how good I was at my job, and how pleased they were to have me as their therapist. This extreme affirmation and massaging of my ego served to hold me back from challenging and confronting the negative behaviours aligned with their addiction. If the client is not challenged then no change will occur. Thus the therapist can only act only as a facilitator for continuing the addictive behaviour and ultimately enables the client to continue to avoid responsibility.
Not Too Close But Not Too Far
Individuals who have had an experience of sexual abuse will either have difficulties with intimacy or distance. This can manifest within session as the therapist must become conscious to create a balance between the two. There needs to be a positive distance from the client without appearing non-engaging as well as creating a positive alliance without breaking boundaries and being too close. It is important for the therapist to be aware of the nature of dependency and how this may impact on the client/therapist relationship.
“In social and personality psychology, the reliance to a higher degree than normal of one person on another (or others) for emotional, economic, or other support”
(Reber and Reber 88:1985).
Once the client has relieved the self from the dependency of the substance or behaviour, this dependency can also be transferred to another object, often the therapist. While in all therapeutic relationships, boundaries are important, there needs to be a heightened awareness of these when working with a client who has had an experience of sexual abuse and addiction.
This may manifest through a desire by the client to learn more about the therapist’s personal life, a need for extra sessions, a desire for advice, and an overall elevation of status for the therapist in the eyes of the client. Often the therapist might feel as though they have been placed on a pedestal where their every word is hung on by the client. In my experience, this can affect the client’s recovery process whereby an individual places the utmost importance on the one to one therapy process and therefore neglecting or disregarding other support services and mechanisms which have previously been put in place to avoid relapse. Whilst this devoted commitment can be positive, the therapist will undoubtedly and naturally fall from the transferential pedestal leaving the client having rejected any other potential support in danger and therefore placing the self in the path of relapse.
When working with an individual dealing with addiction and sexual abuse, the therapist can experience a situation whereby boundaries are tested. There can be an inconsistent pattern of attendance, late arrival to sessions, a difficulty in committing to the process, poor payment of fee etc… These presenting issues, when worked with and addressed, can be invaluable to the individual’s process as the behaviour can often reflect the individual’s attitudes and experiences outside of the therapy space. This can be a prevalent feature for the individual who has been sexually abused and who uses addiction as a way of coping. Trust is extremely difficult. To commit to any relationship is testing and rife with danger for the client who expects to be abused again. Thus to enter into a relationship with the therapist, to give their innermost thoughts, feelings and experiences is high risk.
The Transient Client
The often transient nature of the individual who is in active addiction can add to the difficulties involved in maintaining the therapeutic relationship. There may be no fixed address for the person who moves from one accommodation to another regularly which can add to difficulty in staying consistent with attendance. There may also be difficulties with money management and placing importance or value on sessions and on the relationship between client and therapist.
The individual in therapy may be living with family or a partner and in a co-dependent relationship. A co-dependent relationship is a:
“Mutual dependence such as that between two individuals each of whom is emotionally dependent upon the other”.
(Reber and Reber 127:1985).
This ultimately can influence the individual’s recovery and the therapeutic process. The co-dependent system for the individual is one whereby the person develops co-dependent relationships rather than interdependent ones. They can become entangled with each other and lean excessively on one another rather than standing separate. The person then cannot be autonomous and cannot conduct life according to their own needs and values. A co-dependent’s behaviour can be self-defeating and self-destructive. This can prevent the person in therapy from achieving change in their own lives. The co-dependent partner can often be the one to carry and manage all the feelings within the relationship. This can result in the individual quite literally leaving his/her emotions at home.
I have found it can be very difficult to work with a co-dependent client whose family can seek to intervene in the individual’s therapeutic process. While I worked with a client who had managed his childhood experiences of sexual abuse with the use of heroin, I became harshly aware of his family attempts at intervention and interruption in his process. I was met with phone calls from the family, a demand for confidentiality to be wavered for their information, and an overall attempt to sabotage their son’s healing through the creation of arguments and stresses within the family system. I was later to discover that the threat of their son’s behaviours changing through therapy would mean their roles as enablers and facilitators of the addiction would be challenged. This would ultimately leave them available to explore their own dysfunctional attitudes and behaviours. It was easier and less intrusive an experience for them to observe their son as the problem as opposed to taking responsibility for their absence when he had needed them most.
To work with such an individual brings to the fore the issue of possible relapse. When dealing with such sensitive issues of sexual abuse/violence, the therapist must be very aware of the possibility of potential relapse. Relapse prevention can depend on relationship between therapist and client focusing on issues such as assertion, warning signals to prevent relapse, interventions should relapse occur, phases of recovery and exploration of high risk situations. Positive support structures must be in place for the individual in therapy when managing issues and experiences which have long been buried. Thus the therapist must be educated in his/her knowledge of organizational support, meetings with Alcoholics/ Narcotics/ Overeaters Anonymous etc… and be conscious that the client is consistent in their attendance at such support. The therapist also needs to be mindful regarding re-triggering the abuse trauma which can re-activate the need to withdraw back behind the addiction. It is also important to focus the client on potential support required for their families as often family difficulties and a lack of familial support can play a role in potential relapse.
So what is it to work with the individual as a whole? To me, whole represents the physical, emotional, mental and also spiritual aspects of the individual. Yet the person who has the added experience of addiction as a method of coping with an experience of sexual abuse/violence, may be physically dealing with withdrawals, emotionally disconnected, mentally affected due to years of damage caused by chemical and physical abuse, and spiritually unaware. An individual who has had an experience of sexual abuse/violence can present as being extremely vulnerable, sensitive, insecure, fragile, fearful and isolated. This individual may also present as being capable, competent, independent, controlled and a fully functioning member of society. In my experience of working with such individuals who as a result use addiction as a strategy to cope with such traumatic memories and experiences of sexual violation, is to work with the defenses and strategies used when the substance or behaviour of the addiction is removed. Overall, to work with this client represents the ‘double whammy’ of clinical issues which is not only challenging to the therapist to facilitate such work, but demanding a directive, confrontational, and educative relationship. This can confront and unnerve the therapist’s skills and confidence in sitting with such a barrage of issues, emotions, thoughts and perceptions met. In my opinion it is no wonder that a reluctance exists to work with this individual. However my fear exists that to resist and reject this individual, as has been my experience with some therapists and organisations, is to continue the experience and pattern of abuse the client is very familiar with.
Rachel Somers is a psychotherapist accredited with IAHIP, IACP and IAAAC. She works part time with One in Four and in the Tabor Counselling and Therapy Centre in Tallaght and Mullingar.
Reber and Reber (1985) The Penguin Dictionary of Psychology. 3rd Ed. London: Penguin. Pg. 188
Reber and Reber (1985) The Penguin Dictionary of Psychology. 3rd Ed. London: Penguin. Pg. 127