Working Therapeutically 
With Sexual Abuse – Issues for Consideration

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.

1. An enduring post traumatic stress disorder.
2. Deep damage to ability to trust (self, others, world).
3. Acute damage to self-esteem.
4. Deep emotional pain (sometimes masked).
5. Damage to sexuality.
6. 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.

Basic requirements


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.

Bibliography


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.