After Abuse

to the mental health of adults who were sexually abused in childhood. An increasing number of adult survivors are seekin...

Author: Gita Mammen

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to the mental health of adults who were sexually abused in childhood. An increasing number of adult survivors are seeking healthcare that is specific to their childhood sexual abuse. Many practitioners feel inadequately trained to cope with such a complex issue and the availability of affordable specialists does not match the need. Specific training in such work is still not available and a general appreciation is lacking that healthcare for the adult mental health issues of survivors needs to be abuse specific.

After Abuse

A health practitioner’s guide

After Abuse sets out clearly the complex implications of childhood sexual abuse for a person’s adult mental health. It presents a model of abuse-specific help for health practitioners from different training persuasions. The book’s jargon-free language and numerous case-study examples cut across professional demarcations.

Gita Mammen is a psychiatrist and psychotherapist. She has worked in public, private and academic settings, and has been a member of the Victorian Ministerial Advisory Committees on mental health and women’s health. Gita’s work with adult survivors in individual and group psychotherapy since the 1980s informs After Abuse.

Gita Mammen

After Abuse is essential reading for primary healthcare practitioners in community health, rural health, mental health, solo private practice, and for those practitioners who have been approached by adult survivors for help with health issues related to their childhood sexual abuse.

After Abuse Gita Mammen

Australian Council for Education Research

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ACER Press

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First published 2006 by ACER Press Australian Council for Educational Research Ltd 19 Prospect Hill Road, Camberwell, Victoria, 3124 Copyright © Gita Mammen 2006 All rights reserved. Except under the conditions described in the Copyright Act 1968 of Australia and subsequent amendments, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the written permission of the publishers. The publisher and author advise that while best efforts have been used in preparing this book they make no warranty with respect to its contents being used for a particular purpose. The contents of this book are to be used within codes for practice of each profession. Edited by Frith Luton Cover and text design by Polar Design Typeset by J&M Typesetting Printed by Hyde Park Press

National Library of Australia Cataloguing-in-Publication data: Mammen, Gita, 1944- . After abuse. Bibliography. Includes index. ISBN 0 86431 405 1. 1. Child sexual abuse - Australia. 2. Sexually abused children - Australia. 3. Sexually abused children - Mental health. 4. Sexually abused children - Services for Australia. I. Title. 362.760994 Visit our website: www.acerpress.com.au

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To the survivors of childhood abuse who, in sharing their healing journeys with me, informed the making of this book.

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But though individuals can always feel and do whatever their temperament and constitution permit them to feel and do, they cannot think about their experiences except within the frame of reference which, at that particular time and place, has come to seem self-evident. Interpretation is in terms of the prevailing thought-pattern ... Aldous Huxley, The Devils of Loudun 1952.

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CONTENTS Acknowledgements

ix

INTRODUCTION Is this book for you?

CHAPTER 1 The trauma of childhood sexual abuse Developmental trauma Types of traumatic events Secrecy Adult health aftermath of childhood sexual abuse Adult mental health

1

7 7 9 10 11 13

CHAPTER 2 How service frameworks affect help available to survivors

17

What help do survivors seek? Survivor healthcare pathway Type of agency/practitioner approached by a survivor Service frameworks Relevance of service frameworks to a survivor Current service spectrum How perpetrator work differs

17 18 19 19 21 22 22

CHAPTER 3 Assessment and goal plans

24

Assessment Management plan

25 33

CHAPTER 4 Preliminary considerations, principles and pitfalls

37

Preliminary considerations Principles underpinning transactions Pitfalls

38 39 44

CHAPTER 5 Underpinnings of early abuse-specific work

51

The powerlessness package The assertiveness–anger package

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52 55

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vi

CONTENTS

The intimacy package The insight package The resilience package

57 62 64

CHAPTER 6 Strategies and techniques in early abuse-specific work

65

Aims of early abuse-specific work Principles of early abuse-specific work Content of early sessions Strategies in early abuse-specific work Techniques in early abuse-specific work Worker-related issues in early abuse-specific work

65 66 66 70 76 80

CHAPTER 7 Underpinnings of ongoing abuse-specific work Mental ill health Body-sense and somatic signals Mind-altering substances The matter of personality The issue of insight

81 82 89 93 95 97

CHAPTER 8 Strategies and techniques in ongoing abuse-specific work

100

Aims for ongoing abuse-specific work Principles guiding ongoing abuse-specific work Content of ongoing abuse-specific work Strategies in ongoing abuse-specific work Techniques in ongoing abuse-specific work Collaborate and network, or refer Worker-related issues in ongoing abuse-specific work

100 101 101 104 105 109 111

CHAPTER 9 A note on memory What is memory? Classifications and terms used A comment on ‘false’ memory Relevance of service frameworks Triggers and the process of memory-return Working with memory

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CONTENTS

CHAPTER 10 The social context of abuse-specific mental healthcare The issue A longitudinal view Policy development and research The current situation So what can be done?

vii

128 128 129 132 132 134

Further reading

135

Index

136

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ix

ACKNOWLEDGEMENTS This book has been many years in the making. My indebtedness, too, grew during the process. My primary gratitude remains with the numerous survivors who travelled a segment of their healing journeys with me. All have contributed to my reflections; many are embedded as composite characters in case studies of this book. Several, who had occasion to read material that pertained to them, followed my path towards publication with genuine interest and support. My sincere thanks go to all who read an earlier version of the material—colleagues at St Vincent’s Mental Health, survivors, as well as others. Their comments were vital to its development. As I cannot name some for confidentiality reasons I have decided, in the interest of uniformity, not to name any. I am indebted to the Reece Halsey Agency acting for the Aldous Huxley Literary Estate for permission to use the Huxley quote, and the Australian and New Zealand Journal of Public Health for permission to adapt and reprint the table in Chapter 2, page 18. I would like to specially acknowledge my colleagues in the ASH (Abuse Specific Help) Project—Britt Olsen, Jean Leeman, Julie Anne Garland and Carolyn Van Dort, whose conviction regarding abuse-specific needs of survivors saw me through the lean years. And finally, I am immensely grateful to my now adult children, Kathya, Rohan and Andre, for their unquestioning enthusiasm for my initial writerly leap despite its drastic lifestyle consequence, and for their sturdy support throughout the process.

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INTRODUCTION

Is this book for you? This book is about how a health practitioner could help an adult survivor to address mental health issues related to their childhood sexual abuse. It describes how workers across different training disciplines may incorporate abuse-specific help into their practice. An increasing number of health practitioners in a range of settings currently find themselves in the position of dealing with adult survivors of childhood sexual abuse. Many feel inadequately qualified to do this. Specific professional training in such work is still unavailable. Similarly, adult survivors wishing to ‘deal’ with their childhood abuse are unable to access appropriate abuse-specific work. A general appreciation is still lacking that for people who have experienced childhood sexual abuse, healthcare for their adult issues needs to be abuse specific. Abuse-specific work is not the domain of any one professional discipline or school of thought. Current practitioners in this field were trained as social workers, psychologists, nurses, counsellors, doctors, and so on. They later endeavoured to adapt their techniques to meet the abuse-specific needs of survivors they worked with. If you are a health worker in any of a range of public or private service settings— in community health, mental health, rural health, or private practice, for instance, it is more than likely that, irrespective of your training background, you’ve had a number of clients, who you have known for a while, tell you about their childhood sexual abuse. The following sequence of events may be familiar to you: Your client thinks their current distress symptoms and/or health issue is related to their past abuse. They would like to get some specific help that acknowledges this link. They had a few sessions from a sexual assault agency some years ago, they say, but nothing since. Other health services and professionals didn’t seem geared for this work at the time. Now, with so many people talking openly about their abuse, your client hopes the situation is better and that they will get help that is more specifically related to their abuse. You don’t feel qualified to help. So you assist your client to locate a counsellor. However, some weeks later, your client returns to you saying it

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AFTER ABUSE

didn’t quite work out with the counsellor. Nothing against the counsellor, they say, but they just didn’t click personally. You try again. You ring around and come up with some more names for your client to contact. A couple of months later your client is back. The next person was all right, but too expensive for more than a few sessions. Things begin to look more urgent so you suggest a GP, who starts your client on antidepressant medication. But that was not quite what your client was seeking. What they really need, they say, is to work out the link between their abuse experiences and their ill health. They weren’t ready for this previously. Now, they are. But they can’t do it on their own. You tend to agree. You know that your client most needs the kind of help that will view their adult problems holistically, in the light of their childhood experience of sexual abuse. You’ve known this person for a while and feel that, given a little professional support of the right kind, your client would probably work through many of their issues. So why is it so difficult to find a suitably qualified professional? Surely, you think, there must be lots of professionals around who know about abuse issues. What are you as a primary health worker to do? You don’t feel equipped yourself. After all, you have not been trained in such work. As events turn out, of necessity, you end up giving your client more time. You feel inadequate about this. Are you doing the right thing? You don’t quite know what to make of some of the material that’s coming up for your client. What if you make things worse? But there isn’t an alternative. You try contacting specialists on your client’s behalf. The ones you think might be appropriate are either not taking on new clients at the moment, or are too expensive. Your client is, in any case, increasingly reluctant to go elsewhere... If the above situation is one you recognise, then you’re the sort of person I’ve written this book for. Your situation is one that is shared by numerous primary health workers, who are being confronted these days by complex issues they have not been trained for. The number of adult survivors who disclose childhood abuse these days far exceeds that of suitably trained and affordable specialists to refer them to. There is, however, no simple formula for abuse-specific help. Complex issues like secrecy, or depression, or sexuality, for instance, cannot be addressed by simplistic approaches. The aftermath of childhood sexual abuse is a complex one, and always specific to each survivor. A plethora of relevant factors influences the aftermath for an individual: family support in childhood, for instance, or its lack; social or academic achievements, or otherwise; and many others. In other words, the consequence of abuse for a person is modified by unique strengths and handicaps they develop along the way. Health practitioners often wish for definitive methods and step-by-step instructions to allay their own anxiety about undertaking such work. This book acknowledges


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INTRODUCTION

3

such anxiety and, while it does not provide stepwise instructions, addresses it in several other ways. Above all, the book emphasises the need for a practitioner to stay within the framework and techniques of their professional training. This will allow them to stay within their level of competence. The principles and concepts of abuse-specific work provided in this book are to be regarded as a module to be incorporated into the framework of a practitioner’s training discipline. A general counsellor will, consequently, work with topics such as secrecy or sexuality differently to a counsellor practising in a cognitive-behaviour mode, and to one who is psychodynamically inclined, and so on. This area of work is also a fraught one. Therapists could The principles and worry about being seen as ‘instilling’ memories, or to be concepts of abusetransgressing their client’s personal boundaries, or about specific work provided being caught up in lengthy court processes if their client in this book are to be decides to press charges against the perpetrator. Factors regarded as a module contributing to such issues as well as principles of concepts to be incorporated into to deal with them are discussed in this book. However, the framework of a each professional body is likely to have guidelines for a practitioner’s training code of conduct. This code remains the bottom line for a practitioner taking up abuse-specific work. discipline. Each discipline has its code of conduct and standards— do’s-and-don’ts that guide its practitioners—for good reason. They provide practitioners with criteria for acceptable practice, as well as risk-monitoring measures. A nurse, or a social worker, for instance, has work practices that differ from those of a psychologist, or a GP. Staying within the parameters of these work practices ensures that standardised processes and checks are in place. It allows a practitioner to monitor in their accustomed way, their standard of practice, as well as risk levels. The book discusses the types of risk encountered in abusespecific work, as well as strategies to manage them. Let us consider a counselling example to illustrate this point—that of a social worker, who undertakes counselling sessions with a client. If the client later develops suicidal thoughts, the counsellor would not her/himself, take on an assessment for medication. They would recruit appropriate additional help from either a local GP, or the local mental health team. Having said this, neither is the counsellor at such a juncture likely to terminate forthwith their sessions with the client. The loss of continuity and support would only add to their client’s burden. As we know, many professional disciplines are involved in the delivery of healthcare. This means that adult survivors will be involved with practitioners from various training backgrounds. It is important to note that there is no single correct technique or model for working with a survivor’s abuse-related issues. A joint process between a survivor and their health worker will help to determine the optimal method for each survivor, as well as determine realistically what options are available. Such a choice, as we know, will vary from one person to another and also


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AFTER ABUSE

at different points in one’s life. Availability of their preferred option to a survivor is a different matter. It is dependent on their worker’s skills and backup support. The book makes the point that there are certain principles appropriate to working with survivors. These principles inform the development of strategies. Principles as well as strategies are spelt out here and may be incorporated into service frameworks of healthcare agencies, and adopted by sole practitioners. The techniques used in such work, however, will depend on each practitioner’s training background. These techniques will need to be guided by abuse-specific principles and strategies. Abuse-specific work undertaken by a practitioner needs to continue within practice parameters of each person’s professional discipline. Techniques will hence vary between schools of thought. Examples of techniques described in this book derive from more than one school—those underpinning short-term measures described draw on cognitive-behavioural principles, while the long-term work described here is underpinned by psychodynamic principles. Each is couched within pragmatics of the survivor’s psychosocial context. The book encourages the formation of collaborative networks. Such networks will go a long way towards bridging current gaps in abuse-specific help available to adult survivors. They will allow a first level of abuse-specific work to be undertaken in public sector health services. They will provide a survivor with different components of abuse-specific help, and a health practitioner with backup support when needed. Liaison and collaboration between professionals with complementary skills allow each practitioner to stay within their own competence level. Needless to say, backup, supervision and support networks are of special benefit to sole practitioners. It is useful to bear in mind that this field of work is new. Its genesis lies in the fact that adult survivors are now speaking more openly about their childhood abuse. Most workers in the field are, consequently, relatively new to it. So if you feel that you would like to try and work further with your clients, this book can provide guidance. Given the current healthcare climate, the book focuses on survivors of sexual abuse, acknowledging that many would have also experienced physical and emotional abuse. The book begins by describing, in Chapter 1, the complex adult aftermath of childhood abuse with special reference to mental health aspects. This provides the overall rationale for work described in later chapters. Chapter 2 presents an understanding of how frameworks of services and training disciplines affect the abuse-relevant help available to survivors in current times. Chapter 3 describes a holistic assessment: how a health practitioner would help a client to assess their particular needs, their safety, and risk. This allows goal plans to be formulated and priorities to be allocated. Chapter 4 discusses overall principles of abuse-specific work, risk management, safety measures as well as worker issues. Chapters 5 and 6 give, first the rationale and then strategies, techniques and pitfalls in early

It is important to note that there is no single correct technique or model for working with a survivor’s abuserelated issues.


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INTRODUCTION

5

abuse-specific work. These are to be incorporated into each professional’s particular framework and methods that derive from their training background. Chapters 7 and 8 describe the rationale, strategies and techniques useful in ongoing abuse-specific work. A detailed presentation allows each worker to gauge what aspects they can provide within their competence level, and when they will need to collaborate and network, or refer. Factors that affect networking, collaboration and referral are discussed. Chapter 9 discusses memory issues. Terms and definitions that are often used in confusing ways are detailed. Principles and strategies in advanced memory work and some examples are included in order to provide an overview even though a practitioner working in primary healthcare may be unlikely to undertake such work. An awareness of its complexities would help to demystify the field of work, as well as help a practitioner to stay within their own competence level. The final chapter, Chapter 10 explores the social context of the field’s development and its current parameters. This book is not written as a referenced text. For those interested to read further, a list of suggested material is included. I have been mindful that terms like, ‘client’ and ‘patient’ seem, these days, to polarise readers into an alignment that pits social against biological factors. I have tried to use the term ‘survivor’ where possible. That there are fewer men in the book’s examples reflects my practice sample. With regard to the use of genderspecific language, I have tried to remain non-specific wherever possible. However, in instances where this became inordinately contrived I have opted for the feminine gender, and seek the understanding of male readers. The terms ‘health worker’ and ‘practitioner’ are used interchangeably to maintain relevance of material for health professionals in public as well as private sectors. Confidentiality is maintained in case studies by using fictitious names, as well as the method of constructing a composite example from several survivors’ experience. If using a singular example, I have endeavoured to seek permission. Survivors were incredibly generous and supportive. Without them, this book would not have been written.


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CHAPTER 1

The trauma of childhood sexual abuse CHAPTER AT A GLANCE Developmental trauma Types of traumatic events Secrecy Adult health aftermath of childhood sexual abuse Adult mental health

‘Trauma’ is a term that is used widely these days. It could denote the cause of an injury, or its result. It could pertain to physical as well as emotional aspects. Similarly, we hear of post-trauma counselling being offered to people who have been through bushfires, earthquakes, road accidents, or abuse. Often overlooked, is that while there may be commonalities between various types of trauma, there are also significant differences. This chapter explores the unique characteristics of the trauma of childhood abuse, and its complex adult aftermath. Both will need to inform healthcare provided to adult survivors.

Developmental trauma The adult consequences of childhood trauma differ from consequences of a trauma incurred in adult life. This difference is related to the still-developing nature of a child’s psychological capacity. Unfortunately, such a difference is not always given sufficient importance by those who, for healthcare planning purposes, group adult rape together with the adult aftermath of childhood abuse. To illustrate this point, let us consider a child who is sexually abused by a close family member. This child may not, at the time, perceive anything out of the ordinary in their abusive experience, let alone be able to withstand it. The abusive interaction is part of the child’s construct of the world with regard to how people relate to each other. When such a child does ‘realise’ at a later age, she/he will need to go through a process of re-defining what is normal. A child who experiences a different type of trauma, the death of a parent, for instance, does not go through such a process.


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The point is not that one trauma is any less or greater than the other, but that their specific characteristics have to be incorporated into appropriate healthcare. ‘Susan’ grew up in the country, often spending part of the school holidays at her grandmother’s farm. She described an incident from when she was about nine. One day, Susan stood outside the kitchen door watching a rooster mate with a hen in the backyard. Just then her Nanna bustled out, shooed away the mating birds and herded Susan into the house. It then dawned on Susan that something was not quite acceptable about the behaviour of the birds. Only then did she develop misgivings about her father’s early morning visits to her room. Her mother was always down in the milking shed when the father kept his ‘special’ time with Susan. After the ‘chook incident’ Susan worked out that her school friends did not have similar ‘special’ relationships with their fathers. Another significant issue is that a child victim may also develop unhealthy coping strategies that become entrenched and, in turn, lead to further complexities that require to be addressed. If, for instance, being assertive is counterproductive, an abused child resorts to ‘appease and please’ behaviour towards significant adults. And what might this child use as a coping behaviour? Substance-use, perhaps, in adolescence. So not only is assertiveness going to be an issue for this young person, but also the maladaptive coping strategy of substance-use. These aspects persist into adult life when the now-grown-up survivor seeks help for past abuse. For such a person a generic ‘post-trauma counselling’ would be clearly insufficient. Their post-trauma help will need to be abuse-specifically finetuned. The following table provides distinctive features of developmental abuse. The adult consequences of childhood trauma differ from consequences of a trauma incurred in adult life.

The trauma of developmental abuse Childhood abuse

Adult trauma

Awareness of sexual norms and taboos

still developing

already developed

Perpetrator’s justifications

likely to influence the child to assume guilt

unlikely to influence the victim

Coping strategies

child might develop maladaptive strategies

person uses already developed strategies


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THE TRAUMA OF CHILDHOOD SEXUAL ABUSE

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Types of traumatic events

Another important Another important aspect of childhood abuse is the aspect of childhood intentional nature of the perpetrator’s act. Intentionality abuse is the of the traumatic event has specific consequences for the intentional nature of person at the receiving end, be they child or adult. A road the perpetrator’s act. accident, for instance, or a natural disaster like a bushfire has different consequences from childhood abuse or adult torture. Issues like trust, power and secrecy are specifically relevant for survivors of childhood abuse. These issues are unlikely to be relevant to survivors of an accident for which no particular individual is responsible. For instance, abuse by a trusted adult in a close relationship, such as a parent, has significant implications for the child’s relationships later in adult life. Its consequences are different from the consequences of trauma such as the death of a parent in childhood. The following box provides a way to conceptualise trauma with regard to intention or otherwise. Such an understanding allows the practitioner to select appropriate strategies for a particular client. Types of traumatic events Accidental/Unintentional n individual life events (e.g. loss of a loved one, road accident) n group disasters (e.g. bushfire)

Non-accidental/Intentional individual (e.g. abuse, neglect, torture) n group disasters (e.g. war) n

Related to intentionality is that perpetrators invariably foist justifications upon their child victim. They might describe the abusive acts as part of a caring relationship, for instance; or say the child is to blame for the situation. Perpetrators manipulate and manoeuvre to get access to, and gain compliance from the child. They groom and bribe, or threaten and coerce. Abuse in childhood tends often to occur over a period of time, affecting several aspects of the child’s development: individual coping strategies, interactive skills as well as personality traits. As adults, we constantly compare and contrast norms; checking out our experiences against those of others. Social chitchat, TV and books, for instance, expose us to other families and other societies. These comparisons allow us some objectivity towards our experiences. Despite this we, as adults, often struggle to work out subtle influences that impact on us in everyday life. How much more difficult it is, then, for a child to make sense of their world. A child’s main source of influence and information is their family and school. Social norms and taboos are acquired from their parents, teachers and friends. So what happens when the trauma is caused by one of these persons?


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10

‘Susan’ in the above example experienced abuse prior to her awareness of social norms and taboos. Let us consider some of its consequences for her. Susan had accepted her father’s description of his sexual interaction with her as ‘special’ and a valid part of a ‘good’ relationship. As an adult she had difficulty in working out what was good for her in a relationship from what was not. The distinction between sexuality and affection was often blurred. Her childhood abuse had also negated the solid foundation of trust and security with her father that was essential to Susan’s development. She had considerable adult difficulty to gauge the trust potential of people she associated with.

Secrecy Secrecy that surrounds childhood sexual abuse is an aspect that sets it apart from other types of trauma. Such secrecy often persists for many years after childhood and hinders the survivor from dealing with their health issues, which in turn become increasingly entrenched. Several factors contribute to secrecy—the perpetrator’s bribes and threats, the family’s response and later, societal attitudes. Despite increasing openness about the issue of abuse in society these days there is, nevertheless, considerable stigma still attached to one’s having been sexually abused. Let us consider a very young child who is attempting to describe any ordinary everyday event. We’d note that her/his words and phrases are often facilitated, repeated and echoed by adults around them. It follows that an abused child might not have words to describe what has happened to them, unless helped out by adults in their life. Such help, unfortunately, is not always available. A feeling of having ‘no voice’ is one that survivors describe long after childhood. For a slightly older child such a lack of words becomes linked with guilt, or shame engendered by attitudes encountered in others, the combination fostering silence regarding the issue. A child perceives the world to be run by adults, with adult rules. This is further compounded in adult life by social norms that decree personal sexuality and sex as private. The end result for such a person is that their childhood abuse could remain secret for many years. Secrecy could affect many aspects of a survivor’s life besides the ability to seek help. It plays a significant part in a survivor’s vulnerability, for instance, to re-enact their childhood experiences in adult relationships. Only a detailed consideration of each survivor’s story will allow the person’s abuse-specific consequences to be delineated. Psychosocial context of secrecy n n n

Family conditioning/culture of silence Perpetrator pressure to maintain secrecy Societal attitudes to, and stigma regarding sexual abuse


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11

Adult health aftermath of childhood sexual abuse Survivors of childhood sexual abuse could experience many types of health issues in adult life. For some, these issues may be periodic, or occur at a manageable level. For others, the issues could deepen further into a sustained level of illness. Such a sequence is best regarded as an ‘aftermath’ rather than a ‘consequence’ for several reasons. First and foremost, the outcome for each survivor is multifactorial. It is one influenced by the survivor’s environment as well as the various strengths they’ve had the opportunity to acquire. As indicated in the following diagram, several factors influence the eventual adult outcome of abuse for a survivor: personal strengths and handicaps, the nature of the abuse itself, perpetrator-related issues such as trust, the family environment of the survivor, and the societal environment. These factors are interlinked. Aftermath of childhood abuse: factors influencing outcome for a survivor

Legend Personal factors Abuse factors Perpetrator factors Family factors Societal factors

Another reason to opt for the term ‘aftermath’ is that ‘consequence’, unfortunately, evokes a notion of ‘cause and effect’ that is too simplistic to incorporate the complex range of influences that operate. A reductionist approach could lead health practitioners and healthcare planners, as well as survivors to overlook the complexity of required interventions. And finally, substantiation of ‘causality’ can only come through research, and this will take time to accrue in this relatively new field of inquiry.


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Types of health aftermath Life events mould each one of us. Aspects of a survivor’s abuse aftermath may be embedded in their personality and in their ways to deal with life. Not all are negative. Overcoming hardship and trauma, as we know, could bring out specific positives in a person. For instance, a survivor might develop a certain empathy and perceptiveness for others’ suffering. However, a survivor might not be able to sublimate all aspects of their abuse aftermath into positives. Some negatives may persist in aspects of personality, or everyday functioning—low self-confidence, or undue wariness, to name a couple. Other aspects could evolve to eventually become part of an illness—depression for instance. Health issues for adult survivors could be in emotional, behavioural, or psychosomatic (combined physical and emotional) realms.

Emotions As mentioned earlier, an adult survivor might experience distressing emotions, either periodically, or at a consistent but manageable level for many years, without considering this as an illness. They might, for instance, experience a mix of anxiety and depression—their proportions varying with the survivor’s age. Anger and grieving are other examples. Behaviour A survivor might use certain behaviours to either express or relieve their emotions. The type of behaviour varies from person to person. For instance, one person may binge-eat, another could self-harm, yet another might drink excessively, or become involved in disastrous relationships. Illness There will also be a certain number of survivors for whom an abuse aftermath progresses to assume illness proportions. Such illness could be either mental, or psychosomatic in nature. Adult health aftermath Distressed emotions and unhealthy behaviours n Emotions (e.g. distress, anger) n Behaviours (e.g. self-harm, disturbed eating patterns, substance-use) Illness Mental illness (e.g. depression, anxiety, PTSD, psychosis) n Psychosomatic illness (e.g. chronic pelvic pain, irritable bowel disorder) n


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Adult mental health Let us now consider in more detail, the mental health of adult survivors of childhood abuse. Mental health issues of survivors straddle an extremely wide range. For ease of consideration, these issues have been grouped here into five categories: emotions and feelings, behaviour, interactions, personality traits, and illness. It is useful to bear in mind that such demarcations are not always clear-cut. For instance, distress (an emotion) could be associated with self-harm (a behaviour), or self-esteem (a personality trait) in a depressive illness. Types of combinations could vary for a particular survivor over time. The following table provides examples of each type. Types of adult mental health issues experienced by survivors Emotions/feelings

e.g. distress, sadness, grief, anxiety, anger, depression, guilt, shame, self-blame, confusion, ambivalence

Behaviour

e.g. inadequate externalisation of anger, confusion about sexuality versus affection, disturbed eating patterns, substance-use, self-harm, suicidality

Interactions

e.g. trust issues, assertiveness, dependency, unclear personal boundaries, re-victimisation

Personality traits

e.g. poor self-esteem, low self-confidence, secrecy, ambivalence and boundary issues within close relationships

Illness

e.g. depression, anxiety, post-traumatic stress disorder, dissociative disorders, psychosis, personality disorders

Mental health issues will be discussed in further detail in Chapters 5 and 7 in the context of undertaking abuse-specific work with survivors.

Why such a wide range? The way we cope with, and express our distress varies with age. Coping strategies, at any age, allow us to reduce mental pain resulting from the distressing cause/ environment. Such strategies become more sophisticated as we move from childhood to adulthood, through our capacity to recognise, identify and verbalise distress. A child might show distress by crying or having a temper tantrum. For another child, distress might be mediated in complex behaviours such as bed-wetting, or in learning difficulties, without visible sadness or anger. Adolescents and adults, too, express distress either directly in manifestations of emotions such as hurt, sadness and anger, or, indirectly in more complex social patterns of withdrawal, isolation or aggression. As adults, although emotions might still be mediated instinctively through behaviours, our ability to talk about emotions—and consciously channel them into activity—provides a significant means to deal with distress. These developmental changes are represented visually in the following table.


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Distress manifests differently with age Behaviour

Emotion

Illness

Early childhood

+ e.g. withdrawal, hyperactivity

Later childhood

+ e.g. problems in peer interaction

+ e.g. sadness

Adolescence

+ e.g. acting out

+ e.g. peaks and swings

+ e.g. eating disorders

Young adult

+ e.g. self-harm

+ e.g. anxiety

+ e.g. depression

Adult

+ entrenched behaviours, e.g. poor assertiveness, substance-use

+ e.g. depression, anxiety

++ e.g. mental illness, psychosomatic personality disorder

Behaviour, too, obviously evolves from childhood to adult life. Our childhood mannerisms form the basis for teenage ways. These, in turn, gradually become more complex, eventually developing into adult traits and interactive styles that characterise us as individuals. A child’s personal strengths and interpersonal skills are developed and moulded through relationships and activities. One child might spend many hours ‘mucking around’ with friends; another prefers swimming; another might read. A child’s favourite activity is encouraged and reinforced if significant adults regard it positively. Even a behaviour that is regarded as a problem, temper tantrums or bed-wetting, for instance, could—by generating attention otherwise lacking—be reinforced for the child. The important point is that healthy children develop a range of coping skills through different aspects of their lives. It allows them the flexibility to choose the most appropriate response for each situation. A traumatised child, by contrast, might not develop such a range. Much of their childhood emotional energy having gone into coping with their trauma, their forte might lie, for instance, in coping with a crisis, or in skills to deal with impending violence. Such a child would lack the flexibility in adult life to choose from the responserange available to their healthier peers. They might have to make do with a limited repertoire of, for instance, confrontation and argument, or social withdrawal even if they knew each to be counterproductive. They don’t have a choice, as negotiation might be a skill they have never developed. We can then see that coping strategies—essential in the abusive childhood


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situation—would become increasingly problematic for the survivor in adult life, if used inappropriately in non-abusive situations. As we shall see in Chapters 5 and 7, survivors of abuse with fewer options to channel distress are likely to become entrenched in their childhood coping methods. Continued use of childhood methods into teen age and beyond hinders such a person from acquiring healthier coping styles, making them more vulnerable to later mental or psychosomatic illness.

What about different types of abuse? Is the consequence different for physical, sexual, or emotional abuse? And what about an adult who has suffered more than one type of abuse in childhood, by either the same or different perpetrators? These too are issues that need to inform the help that is made available to adult survivors. It is now acknowledged that the different types of childhood abuse—sexual, physical and emotional—might be equally damaging. Also relevant is that a particular survivor might have experienced more than one type of abuse. Health practitioners undertaking abuse-specific work need to be mindful that the adult aftermath might differ for each type of abuse. Consequently, the survivor will need her/his healthcare strategies to be finetuned to their personal experiences. The following example illustrates this. ‘Rita’ sought help for repeated periods of depression. She was strikingly articulate, and had a strong sense of social justice. Her migrant parents had worked hard, she said, to give her an excellent education. She initially described her childhood as ‘perfectly normal’ adding, as an afterthought, that perhaps discipline had been ‘slightly more rigorous’ than for some of her peers. On the other hand, she added, that might merely have been a cultural difference. Rita valued her cultural background. She’d derived strength from it. She also had a strong sense of privacy and seldom spoke about her feelings. She approached life with stoic pragmatism despite pain-ridden years with a bowel disorder, and periods of depression that made everything ‘too much to bear’ at times. Rita had a keen sense of humour. Initial sessions were rather entertaining, with workplace anecdotes mainly about cultural differences. One sensed that humour had helped her through many difficult experiences. As sessions progressed, Rita’s pervasive feeling of isolation in childhood emerged more clearly. She described disciplinary acts: being made to kneel for hours on a concrete footpath when she was very young, for a minor misdemeanour. Being thrashed with a belt—to instil a respect for truth—for embellishing her retelling of an incident. It took months for other events from later childhood to emerge—the ongoing sexual molestation by a family friend, that she had been unable to stop or


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AFTER ABUSE

avoid. She’d certainly never dared to tell her parents, in case they considered it her fault. There is a fine line, if any, between the severe punishment meted out by Rita’s father, and physical abuse. In any case, it was a significant precursor to the sexual abuse she later suffered. It made her less able to protect herself from sexual abuse by an external perpetrator, and also prevented her from approaching her parents for help. In such a situation it will be insufficient for abuse-specific help to focus on the sexual abuse alone. Appropriate help here will need to be mindful of the family environment and the emotional and physical abuse—‘punishment’ in this case. A survivor’s vulnerability to an external predator in childhood is obviously an important consideration in providing adult help. Each relevant aspect needs to be included in help strategies tailored to the individual.


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CHAPTER 2

How service frameworks affect help available to survivors CHAPTER AT A GLANCE What help do survivors seek? Survivor healthcare pathway Type of agency/practitioner approached by a survivor Service frameworks Relevance of service frameworks to a survivor Current service spectrum How perpetrator work differs

Adults who were sexually abused in childhood seek help from any of a variety of agencies, not all in the field of healthcare. The type of help they receive is, obviously, determined by the type of agency they have approached. This chapter will explore the ramifications of service frameworks for a survivor’s mental heath issues.

What help do survivors seek? Survivors’ presenting issues vary greatly in type, intensity and duration. In the health sector, a survivor’s first point of contact is often a general health agency such as a community health centre, or a general medical practitioner (GP). Some survivors might not specifically request abuse-related help in the first instance, mentioning only their health concern. Others are more direct in seeking help for abuse. People in the latter group might approach an agency dealing with sexual assault or domestic violence. Or they might start their process with a view to ‘right a wrong’ at an agency geared to redress and justice, or advocacy; for instance, at a legal advice centre or the police. For every survivor who seeks abuse-specific help, there are many who do not—for years, sometimes. Many are already in the health system getting help for physical, or mental issues without mentioning their abuse. Others seek help for issues unrelated to health: from women’s refuges, for instance, or agencies involved with homeless youth, or the sex industry. Many are in the prison system for drug offences.


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AFTER ABUSE

The following table provides an overview. Initial presentation abuse as primary concern | to any of a range of agencies |

| to police or legal agency |

with acute noncoping

with chronic non-coping

• • • – –

• seeking redress and justice

distress flashbacks intrusive memories depression/anxiety suicidality

abuse not mentioned | to healthcare or specialist agency

| to other agency/sectors

| • physical symptoms • alcohol/drug problems • mental symptoms – depression – personality disorders

| • • • •

women’s refuges homeless youth prison system sex industry

(Table adapted from the author’s article ‘Primary health care for adult survivors of childhood sexual abuse’, courtesy Australian and New Zealand Journal of Public Health, 1996, vol. 20, no 6, p. 651)

Survivor healthcare pathway An adult survivor’s first episode of ill health is often triggered by a significant life event. This may be either a positive life event—the birth of a first child, for instance, or a good intimate relationship after a series of unhealthy ones; or it may be a negative life event. The period before the onset of illness is often termed a lag period. Its duration varies from person to person. If the help a survivor receives does not take their past abuse into account, although their presenting symptoms may remit with treatment, it stands to reason that there would be less chance of a real resolution. This seems particularly true of people with mental illness. The mental health system looks after many survivors who have accumulated over the years many volumes of case notes and several diagnostic labels. Although a history of childhood sexual abuse might have been recorded years earlier, the fact seldom informs their treatment. To what extent such survivors would have benefited if they had received abusespecific help at first mention is something that will have to be researched when mental healthcare systems include abuse-specific help in their service delivery. In current times, a survivor often goes to a series of agencies seeking abusespecific help.


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HOW SERVICE FRAMEWORKS AFFECT HELP AVAILABLE TO SURVIVORS

19

A survivor’s healthcare pathway First episode of ill health triggered by significant life event Survivor seeks help for health problem abuse non-disclosure

abuse disclosure

symptom specific treatment

possible temporary worsening

temporary remission

abuse-specific work

repeat, varied presentation

more chance of resolution

Type of agency/practitioner approached by a survivor A survivor might approach an agency in either the public sector, or the private sector depending on their priority and finances. Someone who is depressed, for instance, might start their process at a community health centre in the public sector; or with a local doctor whose service is partly covered through Medicare. They might, alternatively, opt for the private sector, approaching any of a range of counsellors and therapists in mainstream healthcare, or practitioners in complementary health. Similarly, a survivor seeking justice and redress—for instance, regarding clergy abuse—might approach a sexual assault centre (public sector), a church agency (NGO), a legal firm (private sector), or a survivor lobby group. Type of agency approached by a survivor n n n n

Public sector: health, welfare, or legal agency; statutory body Non-government sector: health, legal, or spiritual Private: counsellors, therapists in mainstream health or complementary health Survivor groups: self-help, advocacy, lobby

Service frameworks Agencies as well as sole practitioners are guided in their service delivery by frameworks. For the former this may be set down in detailed policy manuals, for the latter it might be an unwritten code of practice that derives from their professional training.


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AFTER ABUSE

Agency frameworks All agencies, whether in the public or private sector, function within a framework that guides their service delivery. Such a framework is likely to include two aspects that affect the help a survivor receives: firstly it would specify the type of service to be delivered by the agency, and secondly, it would ensure that its workers are qualified to deliver such services to a specified standard. A survivor presenting for help will enter a process that is in keeping with the agency’s framework. Each agency would, of course, begin with the survivor’s stated concern. The process after that will depend on the type of agency. Terms used will vary. For instance, a survivor is now variously termed a client, consumer, or patient. The process that follows, too, will differ between agencies. A healthcare agency, for example, a community health centre or a mental health clinic, is likely to use their patient’s presenting concerns to define symptoms that will enable the worker to establish a diagnosis. A medical model generally aims to treat an illness in order to reinstate health. An agency in the welfare system, for example, a women’s refuge or youth service might use their client’s request and presenting information to ensure safety as a priority. This agency might advocate on the person’s behalf and use counselling, as well as other interventions. Agencies that work within a justice framework, for example, a legal agency or a statutory body would proceed with the person’s concerns in a different way again. Here the focus is that of administering justice, not the health and wellbeing of an individual. In this situation, interpretations and findings will lie within existing legislation that safeguards the rights of all individuals, not merely those of the survivor. Evidence will be needed: either ‘beyond reasonable doubt’, or to a ‘best probability’ level. Service frameworks: a snapshot comparison Agency

Welfare

Legal

Health

Emphasis

client’s stated need

existing legislation

symptoms & diagnosis

Mode

counselling & advocacy

evidence is essential

treats illness mainly

Aim

ensure wellbeing

deliver justice

reinstate health

Sole practitioners The task of defining their service framework might not be as clear-cut for a sole practitioner. While individual workers in agencies may have their framework for practice spelt out for them in policy manuals, the issue is not as simple for a sole practitioner. Individual practitioners, however, tend to develop practice guidelines. Initially these might derive from their professional training. Over time, such guidelines are likely to be finetuned as the practitioner accrues experience within a sole practice


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setting. Finetuning might accommodate the needs of the practice location and environment, or the practitioner’s special interests. For a sole practitioner interested to take up abuse-specific work, it is a useful exercise to try and define their practice ethos. A clear understanding of one’s framework helps the vital principle of staying clearly within one’s framework and competence level.

Relevance of service frameworks to a survivor A person requesting abuse-specific help from an agency or sole practitioner is entering a quite distinct process. Frameworks used by different agencies and practitioners affect the help available to survivors. Even strategies that go by the same name may be practised quite differently in each of the systems mentioned above. For instance, counselling is offered as a helpstrategy by many generalist as well as specialist health and welfare services: community health centres, various Frameworks used by NGO-run outreach and support services, drug and alcohol different agencies services, domestic violence centres, sexual assault centres, and practitioners to name a few. affect the help However, the process will not be identical. Yes, there are similarities, but there are also differences according to available to survivors. the type of agency and also the training background of the individual worker. The counselling provided, for instance, by a worker from, say, a nursing background in a general healthcare facility will not be identical to that provided by a worker with a background in women’s studies at a facility dealing with domestic violence or sexual assault. The comparison being made here is not a criticism of either. It merely aims to highlight differences faced by a survivor in various models of help. The following table compares some aspects. Counselling variations In a general healthcare facility

In a facility dealing with domestic violence/sexual assault

Survivor is termed

patient/consumer

client

Likely model

illness

crisis intervention

Sexual abuse regarded as

a private issue

a crime in society

Possible focus

symptoms

power imbalance

Worker–client power gradient

valid (patient ‘receives’ treatment)

invalid (partnership with client)

Interaction with survivor

advisory/prescriptive

participatory/collaborative

Advocacy

not undertaken

undertaken

Networking

less important

important


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Of particular relevance is that in many health and justice settings a survivor often encounters a worker–client power gradient and an authoritarian mode of interaction. Such a model differs markedly from a collaborative partnership model espoused by services dealing with sexual assault and domestic violence. Unfortunately for an adult survivor, the authoritarian mode of a practitioner could parallel their lack of choices in childhood. This issue is particularly relevant to undertaking abuse-specific work and will be discussed further in Chapter 4.

Current service spectrum A survivor who has to deal with more than one type of agency for components of their healthcare is generally ill-prepared for the differences in framework between them. This often leads to much Given the current dissatisfaction and frustration. The current service spectrum dearth of expertise for abuse-specific healthcare is, unfortunately, one that is in this field, fragmented, with little co-ordination. complementary skillCompetition for public funding contributes to mistrust between agencies, and practitioners mostly remain inadsets available within equately aware of the strengths and benefits of service different service frameworks other than their own. frameworks can be Given the current dearth of expertise in this field, used to a survivor’s complementary skill-sets available within different service advantage. frameworks can be used to a survivor’s advantage. Health practitioners who are sufficiently knowledgeable about the benefits of different frameworks can use collaborative strategies to be discussed in Chapter 8.

How perpetrator work differs A brief word about perpetrator work is appropriate at this point. It is well recognised that perpetrators of abuse could have themselves been abused in childhood. However, it is often insufficiently emphasised that perpetrators are generally not successfully treated using the principles and strategies that are needed by survivors who do not perpetrate abuse. Although this book does not have the scope to go into details of perpetrator work, it is important that a practitioner undertaking abuse-specific work with survivors be aware of differences. • Perpetrator treatment strategies require dealing with the denial and justifications that perpetrators use. Such strategies are very different to those required by nonabusing survivors, who, by contrast, might have assumed inappropriate guilt and self-blame. • Perpetrators generally do not take responsibility for their abusive acts. They might rationalise their violence and blame their victim for having ‘provoked’ them. This aspect requires an external monitoring authority to ensure compliance with


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treatment strategies and to stop perpetrators from reIn other words, offending. Successful offender programs are most often perpetrator treatment court-mandated ones at specialist agencies. is a different field A detailed examination of why some victims of of work. childhood abuse, and not others, become perpetrators in adult life is also beyond the scope of this book. Briefly, however, some relevant factors are: • To what extent the victim ‘identified’ with their perpetrator. • The degree of physical violence associated with the sexual abuse, and how the child dealt with fear. • What mitigating factors were available in childhood—did the child have other role models, for instance? • Was there opportunity to develop some healthy coping strategies and positive life skills? • Over time, how much insight did the person develop into the interplay of factors? In other words, perpetrator treatment is a different field of work.


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CHAPTER 3

Assessment and goal plans CHAPTER AT A GLANCE Assessment holistic abuse-specific risk

Management plan agency-specific objectives abuse-specific objectives

Now that we have discussed the distinctive trauma of childhood sexual abuse, as well as characteristics of various service systems, let us consider appropriate healthcare for adult survivors. We would probably all agree that the first step in delivering any type of healthcare to a person is an assessment. This chapter presents an abusespecific assessment that you can incorporate into your existing one. Irrespective of your training background or work-setting you are likely to begin with the specific health issue that brought a client in to see you. You would then probably determine their overall health status. You might also establish other factors that could affect their healthcare outcome. Your assessment process is influenced by the type of service you/your agency have a mandate to provide—disability outreach, say, in a non-government agency— which, in turn, is why the client chose your particular agency in the first place. Your existing format for an intake assessment is likely to draw upon both your training background and your job description at the workplace. Your format might differ from that of a co-worker. For instance, if you are a social worker in a community health service, your client intake-assessment may not be identical to that of a nurse colleague. Irrespective of such worker variations, when it comes to a client seeking abusespecific help, additional assessment information will be required. The assessment module described in this chapter will enable you to help a survivor to define their individualised abuse-specific healthcare needs.


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ASSESSMENT AND GOAL PLANS

Some aspects might already be part of your process. Others could be included. Yet others, of course, might not be appropriate to include: for instance, a physical assessment for someone with a psychosomatic condition, that may only be undertaken by suitably qualified practitioners. Any abuse-specific modification you make to your existing assessment format must still remain within the code of practice for your professional discipline.

Any abuse-specific modification you make to your existing assessment format must still remain within the code of practice for your professional discipline.

Assessment Chapter 2 noted that not all abuse survivors mention their abuse in their initial presentation. Let us assume that your client sought help for a health issue. This might have been an aspect of physical health, if you are a community health worker; their substanceuse, if you work in a drug and alcohol unit; or their suicidal thoughts, if you are a mental health worker. This client would have chosen you either because your agency delivers a certain type of healthcare service or, if you are a sole practitioner, because you have a certain type of expertise. Your initial assessment would have focused on this health concern. We will term this part of the assessment as the agency-specific or problem-specific assessment. You might even have begun to address this aspect. Now it appears that your client’s issues may be linked to past abuse. You will need to undertake some further assessment with the person. Assessment appropriate to abuse-specific healthcare has three components: a holistic component, an abusespecific component, and a risk assessment. Depth of detail takes time, so the time taken by each component of the assessment will vary. It is useful, however, to allocate a defined number of hours overall— perhaps about three, in the first instance. More information will emerge as you continue the work.

Holistic assessment Even if you have known your client for a while previous to their disclosure of childhood abuse, when they come up with this hugely relevant information it is useful to revisit your earlier intake-assessment to fill in more detail. The holistic component of the assessment pertains to your client’s overall functioning. It aims to establish a sense of the person that goes beyond their problem issues. It helps to identify personal strengths and handicaps that provide the basis for individually tailored strategies in early and ongoing abuse-specific work to be discussed in Chapters 6 and 8. The precise phrasing of your questions and prompts in assessment will come from your training background and style of work. Some practitioners allow an


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AFTER ABUSE

unstructured life story recounting by their client, others ask specific questions, yet others use a combination. Use your already developed skills. Remember, at any time during the assessment, if there is urgency with regard to the presenting issue, then that will take precedence. Holistic assessment will then need to be postponed until the urgency has been dealt with. For instance, you wouldn’t attempt an abuse-related assessment with an acutely suicidal person. Information you gather in the holistic assessment should span the survivor’s life in three main areas: • Personal aspects including health issues • The nature of interactions at work, socially, and within the family • Resources and networks available to the person. You will need to get a sense of each of these three aspects during your client’s different life stages. In other words, acquire a longitudinal/historical sense of the three facets over childhood, teenage, and adult life. You could begin either with the person’s current functioning or with their childhood. This depends on your training background and work style. Since you have only about three hours in all, apportion this time. You don’t need too much detail at this stage. Even if you uncover important information, remember you can always go into it more at a later stage during abuse-specific work. Don’t spend too much time on childhood and the teenage years. With regard to childhood functioning, for instance, the assessment might merely elicit that a particular survivor was an outgoing child with many friends, or the reverse—isolated and withdrawn. The client might say their school experience was ‘OK’ or ‘terrible’ as the case may be, or that they began smoking cigarettes at the age of 11. With regard to teen age, the person might say s/he dropped out of school after Year 10, the same year as her first overdose. That, you might learn, was also when she moved out of home. Allowing more time for a person’s teen and young-adult years often provides very relevant information on a developing sexuality, social interactions, coping strategies that were tried and discarded, as well as education and skills development. Substance-use, other risk behaviours, or any run-ins with the law might emerge. Now take time to assess your client’s functioning in adult life. This is likely to take the most time, but perhaps you are already familiar with aspects of it from your previous contacts with the client.

Personal aspects including health issues Each survivor is unique. Personal aspects explored in the holistic assessment should include attributes discussed in Chapter 1, such as secrecy, guilt, shame, as well as other personality traits. Get a sense of the individual’s capacity for assertiveness, and how they manage anger. Establish what their current coping strategies are. Are there times when they cope less effectively? If so, how does this manifest? Do they experience periods of


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depression, for instance, or have panic episodes? It is essential to identify a survivor’s strengths. These will form the basis for new coping strategies that you will help the survivor to devise in the process of abuse-specific work. Replacing unhealthy, entrenched patterns of behaviour will be discussed in Chapters 6 and 8. The holistic assessment should also chart the survivor’s previous healthcare pathway. This vital information that helps to guide a survivor’s abuse-specific healing is, unfortunately, often missed through practitioners’ misguided notions of privacy. For instance, it is useful to know whether your client has sought this type of help It is essential to previously. If she/he did, when? What strategies worked identify a survivor’s for them, and what did not? strengths. If your client has not previously disclosed the abuse to a health practitioner, trace the path of their previous symptom-based treatment. She/he might provide useful insights on the correlations of these health issues with their overall functioning of the time. For instance, your client might have recognised a teenage eating problem to be a coping strategy. Future treatment could then build on previously useful strategies, rather than reinventing the wheel each time, so to speak. And finally, the holistic assessment should also cover forensic issues, if any— run-ins with the law, for instance, drug-related charges, alcohol-related violence, or perpetrating abuse. As mentioned in Chapter 2, these behaviours could require special treatment strategies not covered in this book. It would be important, therefore, for the holistic assessment to make sure that your client does not require this other type of assistance.

Interactions Assessment of your client’s interactive patterns in adult years should include those at work and in social settings, as well as within intimate relationships. Patterns related to aspects such as trust, anger, dependency, and personal boundaries are useful to pay particular attention to. Re-enactment of childhood patterns and re-abuse, if any, in later life are important to note. Information on interactions will assist you to personalise for each survivor early and ongoing abuse-specific strategies (to be discussed in Chapters 4 and 6). In complex abuse-specific work (discussed in Chapter 8) it will be vital, in addition, to understand and monitor interactions between you and your client. Available resource networks Get a sense of what resources are available to your client. Is their family supportive? Does your client have a job? Is there a social network to draw upon, or are they isolated? Such information allows you and the survivor to get an idea as to what aspects of care might be needed besides your own. It allows you to envisage the type of complementary skills that would need to be recruited at a later stage from another practitioner.


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Don’t be in a rush to refer a survivor away. Even if there is urgency about getting extra help, as with a person’s escalating suicidal intent, try not to bow out completely. This survivor has chosen to disclose their abuse to you rather than to another person. Hear them out. Completing a holistic assessment will provide them with an overall plan for future abuse-specific work, even if they undertake only certain components with you. The person you refer them to may not take a similar holistic approach. Holistic assessment Developmental aspects: childhood, teenage Adult personal aspects: e.g. secrecy, guilt, self-esteem, self-confidence Previous healthcare pathway Interactions: home, work, social e.g. personal boundaries, trust, dependency Resources and supports

The above aspects are only examples of what can emerge when the assessment adopts holistic coverage allowing time for detail.

Abuse-specific assessment Some overall remarks first, on the abuse-specific component of your assessment: • First and foremost, the discussion should be routine and matter-of-fact, and no different to other components. • If you notice that your client is uncomfortable about answering a certain question, ask whether they wish to leave it for another occasion. This helps to put them at ease. The survivor might regard probing at this early stage as voyeuristic or showing undue curiosity. • Remember that, particularly in this segment, the survivor needs to be in charge, not you. Pinning them down with questions, so to speak, is not appropriate. Given these considerations, some information about the following aspects is needed. Basic information will suffice. When your client is more comfortable in the work, she/he will, of their own accord, return to details.

Duration and frequency of the abuse Over what period—between what ages—did the abuse occur? If the abuse was repetitive, try and gauge its frequency. However, survivors often find it difficult to estimate this. Nature of abuse The survivor is likely to find this aspect difficult to speak about, particularly if they have not done so previously. Explain that you don’t need too much detail at this point, just something that will give you ‘a sense about the abuse situation’. This reassures the survivor. You might use words along the lines of, ‘Tell me what you


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are able to. I might need to ask a few questions if that is all right with you’. Explain that more emerges over time if the survivor needs it to. Essentially, what you need at this initial stage is some basic information—was the sexual abuse of a contact or non-contact type? Was it genital, or non-genital? Was it penetrative? Was it associated with physical violence? Emotional abuse is inherent to both sexual and physical abuse. It is also relevant to bear in mind other types of emotional abuse such as mind games or power games. This might have been perpetrated either by the sexual abuser or by another person. Your aim in establishing the above aspects is to get a sense of the survivor’s experience of their abuse; not to judge the severity or otherwise of the abusive act. However, going into details of a person’s traumatic experience will not be possible in the limited time available for an assessment. Explain to your client that should they wish to go more into detail, there will be time for this later. Disclosure work, as it is termed, is discussed in Chapter 6.

Some complex correlations The type of abuse—sexual, physical, emotional, or a combination—that the survivor experienced in childhood contributes to each person’s distinctive adult aftermath. For example, a seductive type of sexual abuse in childhood—one disguised as ‘caring’— may lead to an adult difficulty in distinguishing between affection and sexuality, and in maintaining personal boundaries. Similarly, physical abuse that generated extreme fear in childhood could contribute to an excessive adult need for control over their own as well as others’ lives. Experience of violent sexual abuse in childhood could result in extreme combinations of both the previous sets of characteristics. Correlation between the type of abuse your client experienced and its adult aftermath might not be possible at an assessment stage. It might only be worked out in later stages. Perpetrator aspects Some perpetrator-information will be needed. Who was the abuser? A family member—a parent, a sibling, older by more than five years—or someone outside the family? This information will have a bearing on later issues such as trust for the survivor. If not a family member, was the perpetrator in a position of responsibility and trust? A teacher? A family friend? Clergy? How was trust misused by the perpetrator? Lies, grooming and bribing are examples of relevant information, if available. Did the perpetrator manipulate the power gradient to their advantage by using physical violence, or a different type of interaction? Such information is useful, if available. It helps a survivor later in working to overcome their sense of powerlessness. It is also very relevant to know whether your client has ongoing contact with their childhood perpetrator, even if this contact is not currently of an abusive nature.


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30

Delineate re-victimisation Re-victimisation after childhood is useful to check for at this point. This could have occurred in an intimate relationship, or in a work, or social setting. Discuss previous help Ask when they first disclosed their abuse to a health professional. What help did they get? What was useful? Determine advocacy, statutory and legal needs Determine your client’s priorities for aspects other than health. Are they seeking some form of advocacy? Do they wish to go down a justice-seeking path? Are they seeking recompense? Do they wish to press charges? Abuse-specific assessment n n

n

n n n

Duration and frequency Nature of abuse: sexual, physical, emotional, combination – regarding sexual abuse—determine whether it was contact, if so, whether genital/ penetrative Perpetrator details: whether in a position of trust, responsibility – nature of interaction used for power gradient – any current interaction with perpetrator Delineate any re-victimisation in later years: at home, work, social Discuss previous help: what worked, what didn’t Determine any advocacy, statutory and legal needs

The precise nature of each survivor’s abuse situation is unique. The direction your assessment needs to take with a particular client emerges only once you start the process.

Risk assessment Potential risk for your client is probably the aspect that concerns you most about involving yourself in this field of healthcare. You know the work is likely to be complex. Your client is functioning at a manageable level at the moment. Could you worsen their situation by allowing them to open up troubled aspects of their life? What if they become suicidal? On the other hand, you are also aware that the reverse might be equally true for them—the lack of scope to deal with their complex issues is central to their ongoing despair. Your client feels that exploring abuse matters will actually make them feel better, not worse. You tend to agree. Such a situation is precisely where a risk assessment proves invaluable. It allows you, together with your client, to delineate potential risk. It also provides a tool for re-use during worsened periods. Such continual risk awareness allows safety measures to be put in place. You could recruit extra help for your client when needed from the local mental health team or a GP, for instance.


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Working with an abuse survivor does not mean you have to take on extra risk. Monitoring ongoing risk allows you to recognise levels that exceed your capability and practice norms, and to adopt your usual protocols to handle such a situation. Risk assessment should be undertaken routinely as an intrinsic component of the initial assessment with every survivor. Such pro-active assessment also gives more information than an assessment made during a non-coping period. The initial risk assessment has three components: • It identifies the type of risk your client is susceptible to. • It gauges the risk level. The initial level gives you a baseline against which to measure any future deterioration. • It identifies your client’s customary strategies to cope with distress. An awareness of these coping behaviours will later alert you and your client to impending escalation of risk. For instance, a certain client may binge-eat, or escalate their marijuana usage for some weeks before they actually recognise themselves to be depressed. Take time in the assessment to discuss each of these three components with your client. The discussion provides mutually acceptable ways to recognise and acknowledge deteriorating coping levels in the future—before they build to crisis proportions. It also allows you to ascertain what resource networks are available to your client. A dearth of existing backup allows you to foreshadow the type of additional resource to be recruited, should the need arise.

Type of risk There are several types of risk to be aware of in working with an abuse survivor.

Suicidal ideation Suicidal thinking of a client is an aspect that concerns all health workers. By the same token, it is also the eventuality that is most prepared for. Each professional discipline and each agency is likely to have practice guidelines regarding it—what a practitioner is entitled to handle, and what would need the recruiting of additional expertise. Guidelines vary from one discipline/agency to another. If you are a sole practitioner, you will have further finetuned guidelines to suit your work situation. Stay within these parameters. Risk behaviours For some survivors of abuse, suicidal thinking might not be the main type of risk. Some self-harm physically, others put themselves into harmful emotional situations. For others, risk situations might involve substance-use or sexual risk. Ask your client to describe how they think they put themselves at risk. Get details of these behaviours. Dissociation Risk from dissociation is not uncommon for survivors. Dissociation is a term that is used with quite different meanings by various people. To some it signifies an ‘out


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of body’ experience. For others it is a type of psychological mechanism. Yet others regard it as a psychiatric syndrome. Clarify what a survivor means when she uses the term. Certain types of dissociation can be very difficult to recognise while they occur. Often, a survivor realises a dissociative period only in retrospect. Dissociation is discussed further in Chapter 7. The nature of questions you will use regarding each type of risk will depend on your training background and framework of service. Review your customary methods to gauge suicidal thoughts, for instance, with any client. Asking a survivor would be no different. You might, for instance, enquire about the nature of the person’s current distress, and whether they are experiencing suicidal thoughts. You might also pick up non-verbal distress signals. If you are unsure, consult.

Level of risk Each professional discipline has specific ways to gauge the risk level of a client. Each also has a different limit with regard to handling risk. If you are an outreach worker in a youth agency you will look out for different aspects compared to someone who is a social worker in a mental health agency. You will need to stay within your practice guidelines. Having a clear notion of your limit in this regard is the key to safe practice. Foreshadow that extra expertise may be needed if the risk level exceeds your capacity. Establishing a client’s risk level at a particular time consists partly of identifying how many of their customary danger signals they are experiencing. Another useful tool is to establish a scale of coping. This is described in Chapter 4. Risk level is inversely linked to coping levels. The lower the coping level, the greater the risk level. Remember, all these tools are to be used within the parameters of your training discipline and service framework; don’t bend these parameters. Risk monitoring and maintaining safety are discussed further in Chapters 4, 6 and 8.

Identify customary coping strategies Every person has his or her unique ways to cope with distress. Some of us bingeeat, some go on a shopping spree, some act out in anger, others turn their anger on themselves and self-mutilate. Coping strategies involve a range of behavioural and psychological mechanisms unique to each individual. Your risk assessment with a client should identify the strategies she/he uses in times of distress. This provides valuable clues to help identify a future period when distress might be building up without any other more obvious signal. A question along the lines of, ‘What methods might you generally use to ease your distress?’ could bring a range of answers. It is also useful to identify your client’s characteristic psychological mechanisms, if possible. For instance, do they tend to internalise their anger, or act out with it?


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Risk assessment n

n n

n

Identify the type of risk the survivor is vulnerable to: e.g. suicidal intent, self-harm, risk behaviours, dissociation Gauge risk level Identify customary strategies to cope with distress: e.g. binge-eating, substance-use Identify characteristic psychological mechanisms if possible

Management plan The assessment is over. You have identified your client’s abuse-related issues and also the nature and level of risk. You have previously delineated their health concerns. Now you can safely discuss goals, and come up with a management plan. Even if you decide that addressing their current risk is the priority, and they have to go elsewhere for this, you would still have helped them to map their subsequent overall plan. A management plan for an abuse survivor should at this stage have two components: • The first relates to this client’s reason for presenting to your agency—for instance, their substance-use, or for help with their depression. Let us term this as dealing with the co-morbidity, or the agency-specific objectives. • The second component pertains to what the client wishes to do about their childhood abuse. We will term this the abuse-specific objectives. As noted earlier, both aspects are important, because symptom management alone risks chronicity of illness, and a revolving-door syndrome.

Agency-specific objectives As noted above, the client might have approached you with a mental health issue such as depression; a behaviour such as an eating disorder, self-harm, or substanceuse; or a current life situation like family violence. Strategies you adopt with regard to these will be intrinsically linked to your agency’s mandate—or yours, if you are a sole practitioner—to deliver a certain type of healthcare. For this aspect, you have a customary mode of working, practised techniques, and a framework within which you function. This book assumes that you will continue to address this aspect of a survivor’s healthcare in your usual mode. Agency-specific objectives will not be discussed further in this book.

Abuse-specific objectives A survivor is likely to find it difficult to identify their abuse-related objectives. Many might merely express a distress-laden wish ‘to do something about the abuse’, without knowing what this might involve. Now is the time to help them think it through.


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The assessment you have just undertaken provides a solid basis for a discussion of abuse-specific goals.

Goals First formulate a long-term goal overview. This is a useful exercise. Discuss what your client thinks would benefit them in a hypothetical ‘ideal’ healthcare world. This helps a survivor to be aware of what is needed, as well as what aspects they can, in reality, access. The exercise will also delineate aspects that are just not possible given both the current dearth of expertise, as well as the costs that might be involved. Knowing their ideal goals often enables a person to improvise and substitute components towards an overall resolution. A succinct one-line summary of their goal will help. This should not be a ‘I want to be happy’ type of generality. It should include specifics. An example might be: ‘I want to work out how my childhood abuse figures in my marijuana use so I can stop being dependent on it and hold a job for longer than a year’. You would note that such an encompassing statement comprises three goal facets: it pertains to current substance-use, to past childhood abuse issues, and to achieving potential in the future. Each of these facets is complex, and needs exploration and fleshing out of detail. Their interrelation will also need to be discussed. For abuse survivors, only then will implemented strategies be successful in the long term. Priorities The next step is to work out abuse-specific priorities. For instance, might your client, at this point in time, be primarily seeking help for distressing flashbacks? Or, perhaps, they wish to deal with longstanding self-harm behaviour and internalised anger? Or is it redress they seek? Priorities with regard to abuse issues determine what your client needs in the way of help: • in the short term, and • the long term. A certain person might give priority, for example, to stop having periodic flashbacks, or at least be less affected by them. She would then like to feel less angry towards her mother, who, your client feels, could have done more to help in the past if she (the mother) weren’t as caught up in her own issues. And in the long term, your client thinks she might like to do a course in her ‘one talent’ of jewellery-making, so that her work is eventually more personally satisfying. The first two components of her overall plan, to do with flashbacks and her relationship with her mother, will need abuse-specific help. You and she will now need to discuss the particulars of what and where she can actually procure such help. You might be able to provide her with some interim sessions until she finds someone for longer-term work. Or you might feel able to provide her with quite a bit of help, now that you both know what is involved.


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Irrespective of what you can contribute towards a survivor’s abuse-specific objectives, such a client is now clearer as to what they need. You have helped your client with the essential prerequisite to their path of healing. Objectives Agency-specific objectives n Develop strategies to manage the co-morbidity (e.g. substance-use, depression, family violence) Abuse-specific objectives n Discuss overall goals n Identify priorities n Determine advocacy and redressal needs

Time plan Clarity about their abuse-specific objectives invariably leads a survivor to ask how long these might take to achieve. This is difficult to estimate. Each person works at a different pace. The nature of one person’s ‘resolution’ will be different from another’s. The degree of resolution also varies at different points of one’s life. It is not uncommon for a person to feel sufficiently benefited in a few months and decide to stop, only to resume a different level of help-seeking after a few years. Differences in ill-health symptoms and type of coping-behaviour, too, influence the time a survivor might expect to take in this work. It helps to point out that longstanding, habituated behaviours will, understandably, take longer to change. Discuss the validity of such individual variations with your client, as it is quite common for survivors to compare themselves negatively with others. Depending on the complexities involved, abuse-specific work can be divided into: • Early work, and • Ongoing work. Each type of work will need appropriate safety measures to be in place.

Preferred strategies and realistic options The next step is to determine your client’s preferred strategies. For instance, one person might say they would like to enter a talk-process, another might seek ways to relieve their symptoms of anxiety or depression, yet another might wish to work on behaviour change. Such a discussion might not be easy for the survivor. They may not know what will suit. They want you to tell them what is required. Don’t panic. The holistic section of the assessment has provided you both with an overall sense of the person, not just their problem. You can help them think through their preference. What strategies have they used in the past—not necessarily for abuse, but to help with


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other problematic issues? Do they sit and think about these issues, or are they more of a doer who tries out various options? Are they only seeking medication for depression at present, or are they wishing to avoid just this? This discussion needs to be a realistic one. It is pointless, for instance, if you are working in a remote community centre to come up with options and preferences that are not available in the region. Given the current difficulty in accessing abusespecific work, viable strategy options might also depend on your training background and skills. You and the survivor need to discuss the match between what you think you can provide, and their preferred strategies. Bear in mind that they have chosen to disclose their abuse to you and not to another health worker. This would indicate that some of the compatibility issues—between your skills and their need—have already been matched. Discuss what you are able to attempt together. Part of this discussion will pertain to managing potential risk while they are working with you. Also discuss the components they will definitely have to seek elsewhere, for instance, advocacy issues or harm minimisation for substance-use.

Verbalising the plan outline This has been a collaborative process. It is now important for you to verbalise where you, together, have arrived. Your client benefits from hearing you summarise the process they have undertaken with you. More than likely, they have been to several agencies previously where there has been no recognition given to their past abuse, or its possible relevance to their current heath status. Your verbalisation will provide a validation of their issues. Your verbalisation should not merely be an idealised motherhood statement of a need for abuse-specific work. It should be specific and detailed. It should also include realistic abuse-specific options. The following scheme suggests aspects you might cover: 1 Track your client’s previous healthcare pathway to confirm what has already been achieved. 2 Identify components of future healthcare goals and how each will be achieved: a Co-morbid health goals (e.g. regarding depression or substance-use): How will these goals be achieved concurrent to undertaking abuse-specific work? b Abuse-specific goals. 3 Mention priorities allocated within abuse-specific work. 4 Highlight preferred and realistic strategy options. 5 State what you can contribute within your framework and what will need to be sought elsewhere. 6 Reiterate how risk will be monitored. 7 List strategies that will be used to maintain safety during the process.


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CHAPTER 4

Preliminary considerations, principles and pitfalls CHAPTER AT A GLANCE Preliminary considerations gender issues process issues

Principles underpinning transactions power issues trust issues survivor control of pace foundations first, superstructure later

Pitfalls managing risk survivor-related issues worker-related issues

The assessment is over. You have helped your client to compile an overall plan and allocate some priorities. You’ve also decided that you might have to squeeze some regular sessions into your already overloaded schedule—perhaps once fortnightly; maybe just until your client finds an expert, you think. You’re uneasy about this arrangement. But nothing else seems available. Don’t panic. This chapter is devoted to precisely such a preliminary stage. The chapter will describe general principles of abuse-specific work. Remember that you will be continuing to work within the framework of your training background. This is familiar territory and provides guidelines as to what you may or may not take on. Abuse-specific work described in this book is merely a module incorporated into the framework of your professional discipline. Your duty of care is determined by: • your training background, and • the service framework of your agency, or if you are a sole practitioner, your own framework.


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Your training discipline has dos and don’ts for practice. Stay within them. It is important not to take on practices and interventions that your background training does not qualify you for. Recruit additional help from colleagues in appropriate disciplines for these other aspects. Undertaking abuse-specific work does not mean you have to founder, or take on extra risk. If at any stage you are unsure of the implications of a survivor’s symptoms or behaviour patterns, recruit additional help just as you would with any other client. It is also useful to bear in mind that too early a referral might not be in your client’s best interest. Such a step would mean that trust they have developed in the process with you will need to be rebuilt with a new worker—an uncertain and/or lengthy process. This chapter sets out principles for interactions between a health worker and client in abuse-specific work. It begins with gender issues and an overview of the transactional process. It then discusses how to manage risks that were discussed in Chapter 3, in order to maintain your client’s safety. And finally, this chapter gives pointers for your own needs in taking on this work.

Preliminary considerations Remember that maintaining a holistic approach is important at all stages of abusespecific work. And you are probably already doing this. For instance, if your client initially sought you out for physical ill health, it would be vital to keep addressing that in addition to the abuse they later disclosed. Addressing each issue benefits the other issues: for instance, the wellbeing that comes from successful asthma-control routines provides the survivor with a sense of control over their ability to tackle abuse issues. As regards abuse-specific work, an awareness of gender issues, and having an overview of the likely transactional process with a particular client are important early considerations for the practitioner.

Gender issues Working with someone who was sexually abused requires a practitioner to be mindful of gender dynamics in interactions. A survivor who was abused by a male may have problems with a male worker, for instance. On the other hand, they might not, in every instance. Similarly, a survivor Working with abused by a female might have difficulty with a female key someone who was worker. sexually abused The issue at this stage of the work is that a survivor requires a practitioner should have a choice with regard to the gender of their to be mindful of health worker. Such choice might have already been gender dynamics in exercised by virtue of the fact that this client has voluntarily interactions. disclosed their abuse to you. However, the issue needs to be


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verbalised. It might only take a question along the lines of: ‘Your childhood abuser was male. Could my gender then be a problem?’

Process issues Transactions between a survivor and their health worker might be regarded as comprising some stages. Each stage has a core issue that needs a suitably matched response from the worker. For instance, a survivor who has only recently become aware of their need to ‘do’ something about their past abuse is aided by their practitioner assisting them to identify their key issues. An appropriate intervention at this stage might be to facilitate verbalisation. Similarly, a survivor’s process of abuse disclosure would be assisted by sensitive competence on the part of a worker, who provides information as well as crisis support. Different types of abuse-specific work require a worker to be knowledgeable, competent and able to set limits. The following chart matches each stage of a survivor’s process with an appropriate worker-response and an example of a helpful intervention. Many of these transactions will occur quite naturally in the course of your interactions with your client. Needless to say, these aren’t always neatly separated into the phases as presented. And, of course, they will vary from one survivor to the next. Overview of transactional process Survivor process

Worker-aim

Intervention

Abuse awareness

to help identify issues

facilitate verbalisation

Abuse disclosure

sensitive competence

crisis support provide information

Abuse-specific plan

define client goals gauge worker competence set parameters of work

offer abuse-specific skills network collaborate

Remember: too early a referral may be a setback for the survivor who has chosen to disclose to you.

These aspects will be discussed further in Chapter 6.

Principles underpinning transactions Some general principles need to inform each of the above transactions between a survivor and you, their health worker. The healing process for a survivor needs to be as far removed from their abuse experience as possible. This means that your interactions with a client in abuse-specific work need to be in specific contrast to your client’s abusive experience in childhood. For instance, the abuser is likely to have used their age, authority and a power imbalance to the survivor’s detriment. Your client will benefit immensely from


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interactions with you that are equal and collaborative. The abuse was a violation of the survivor’s trust. Your interactions with the survivor must build and maintain trust.

Power issues Survivors aren’t always aware of power imbalance in interactions. Neither might they be aware of falling into their old patterns of powerlessness. It is the practitioner’s responsibility to be mindful of this issue. Equality in the Although your client might defer to you and sometimes interactive process even seems to encourage your dominance, it is your role to and a collaborative be mindful of implications for re-enactment of their past. style with regard to As discussed in Chapter 1, a certain survivor’s experience advice and opinion might well have been that any assertiveness in childhood help to counter the was counterproductive. An eagerness to please might have past power imbalance. been their survival strategy at the time. This, along with a need to be looked after, might lead such a survivor to defer to people in authority—a professional, for instance. Equality in the interactive process and a collaborative style with regard to advice and opinion help to counter the past power imbalance. A collaborative type of interaction might be inherent within some training disciplines—social work, for instance. Workers in frameworks with a ‘prescriptive’ manner of telling people what’s required—such as medical, or legal—might need to strive more consciously to work collaboratively with a survivor. Chapter 1 discussed a range of childhood experiences recounted by survivors— unpredictability of their abuser’s behaviour for instance, violence from the sexual perpetrator or from another person. Each of these could contribute to a survivor’s sense of confusion. Survivors who have experienced a seductive type of sexual abuse may have particular difficulty in recognising the power imbalance that is inherent in it. Your assessment process alerts you to each survivor’s particular vulnerability.

Trust issues Abuse-specific work requires trust, and building this takes time. Consistency in your approach will help to counter the unpredictability your client experienced from their abuser. Your clarity of communication helps to build trust. Your clear statements will contrast with the client’s past experience of ambiguity and falseness. Explain your rationale at all times. Such transparency counters the confusion generated in the survivor by the perpetrator’s behaviour and words. Unequivocal and reiterated statements that a child is not to blame for their abuse help to negate the survivor’s self-blame, and help to build trust.


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Survivor control of pace Even a survivor who sought sessions specifically to speak at length about their abuse experience might not do so immediately. The actual material that emerges in early sessions is quite varied. It is not uncommon to find that once regular sessions It is essential, in start, abuse material goes off a survivor’s agenda for a abuse-specific work, period. Instead, to your concern, you find your client for the survivor to using the time to discuss day-to-day issues. This is OK. control the pace of the It merely indicates that the work is being paced by the process. survivor. Slowly, over time, you will begin to make out the relevance of the material being discussed to past and present triggers. Day-to-day material also helps towards devising containment strategies to be discussed in Chapter 6. It is essential, in abuse-specific work, for the survivor to control the pace of the process. Your role in this regard is to stay mindful of the overall process. This allows you to be aware of considerations related to each stage of such work. For instance, if the survivor embarks on a process of ‘disclosure’—detailed in Chapter 6—you might alert them to possible temporary worsening of symptoms. Being prepared for this is immensely helpful for the survivor. With a self-paced method, the survivor generally comes up with relevant abuse material at a time when it is healthy for them to do so. This usually occurs once a safe interactive space is sensed and established. So forcing the pace could be counterproductive. The manner in which abuse material emerges varies from one person to the next. While some survivors opt for a detailed recounting of their childhood abuse, along with much expressed emotion, others do not. You, the worker, are not able to guide this. Trust the survivor’s instincts to guide the process. Specific and direct questions might not always assist. Prompts and responses indicating that you are attuned to hearing their issues might work better. Your professional skills, empathy, and the fact that you are not caught up in the survivor’s sense of helplessness allow you a more objective view. A survivor-controlled pace often takes the form of a period of intense sessions followed by a period where ‘nothing’ seems to happen. This can be a source of frustration for a worker. You may feel that either the survivor is not motivated enough, or that you are not skilled enough for the work. Be patient. It is useful to bear in mind that the ultimate goal is a survivor’s healthier functioning, not a theoretical goal to extract a detailed account of the abuse. Some survivors may never talk in detail about their abuse. Whether they will, or not, is determined by them, not by you, the worker. Facilitating a survivor’s control over the pace of work is as important in short-term abuse-specific work, as it is in a long-term process. The issue of time constraint is one that comes up regularly in this field of work.


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If, for instance, you’ve allocated six months of weekly or fortnightly sessions to a survivor, and three months have passed you will, understandably, be concerned that your client is not making the best use of their time. You’d have preferred that she/he speak at length about their childhood abuse. Do you, in such a situation continue to endorse the principle of survivor control of pace? Is there anything that can be done, and still avoid intrusive strategies that might create a power imbalance for the survivor? Here is one option. The fact that you both jointly outlined goal plans after the assessment now comes in handy. You could raise your concern that only three months of the allocated time remain for your client to cover what they had initially intended to. Your concern might prompt a change of content and pace; or it might not. This is your client’s choice. The strategy, however, allows the survivor to still be in control of the pace of work. A survivor’s control over their pace may not always be clearly thought out and consciously implemented, as the followed example illustrates. ‘Margaret’s’ initial request for abuse-specific help was triggered by anxiety and panic. Following the assessment and feedback, she remained in onceweekly sessions for a few months. She then began to reduce the frequency of sessions, stating unavoidable work and holiday commitments although still maintaining that the previous frequency was her preferred one. Margaret regarded these life events as impeding therapy. My suggestion that perhaps her emotionally optimal pace was slower than one she intellectually allowed for, was not acceptable to her. Although Margaret saw me only a couple of times in the next year, she considered herself to still be in therapy. Margaret returned to her next stint of regular sessions a couple of years later.

Foundations first, superstructure later Tackle simple goals before taking on more complex ones. However, what is simple for one survivor may not apply to another. For instance, overwhelming distress might cause a survivor to be strikingly inarticulate about specifics of their current emotional state. They might be able to come up with only extremely vague statements about what they are experiencing. Achieving clarity would, in such a situation, be an early goal. The following example is lengthy, but illustrative. ‘Shelley’ was seldom able to meet my eyes in early sessions. With hair swung across her face she invariably sat with bent head, eyes on the floor, occasionally darting a quick look at me. Her voice was mostly an inaudible mumble. My own sounded over-loud by comparison as I tried umpteen variations on, ‘Sorry I didn’t hear you’. My question at the end of assessment, as to what she wished to achieve in therapy, was just too difficult for her.


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Shelley attempted a reply. She threw her hair back, tried to find an opening word or phrase, seemed to go blank and went red in the face then withdrew again behind her curtain of hair and sat in silence with bowed head. ‘It’s difficult isn’t it?’ I said in a reassuring tone. Shelley darted another glance at me. I met her eyes, encouraging but careful to avoid appearing pushy. ‘I’d like to look at the more difficult stuff in my childhood, that I haven’t been able to as yet. But I am scared’, she said after a while. I waited, sensing that she wished to continue. In a burst, looking straight at me, she said, ‘I’m crazy’. ‘How do you mean, crazy?’ I asked. ‘Mad.’ The pause that followed indicated to me that Shelley was not going to elaborate on this. So I responded, ‘Shelley, now that we’ve completed the assessment, I can say that nothing in what I’ve heard indicates madness to me’. Once again there was a long pause. ‘There’s always several conversations going on in my head. It’s as though I have two or three different consciences’, she said. I could see Shelley wanted my opinion on this. Did this not indicate craziness? was her unspoken query. I hadn’t found any evidence for a psychosis in the assessment. Shelley had also struck me as an extremely reasonable and insightful person. Her use of the term ‘different consciences’ seemed in keeping with this. ‘Is it possible, perhaps’, I half-asked, half-suggested, ‘that you are a person who is aware of different sides to a situation and see different points of view clearly?’ I continued, ‘In which case, the conflicting consciences [I used her terminology] are to be regarded as an asset in your personality rather than a feature of madness’. Shelley was obviously calmed that I viewed something that she had considered as a disability to be an asset. ‘It drives me crazy. It is so confusing’, Shelley responded. ‘When does it happen?’ I asked. ‘All the time, every day.’ I explored this further: ‘Well, can you give me an example from today, that made you think you were mad?’ ‘I had to make a phone call today. I had to. He has access to so many children. I have to make sure that he does not do to them what he did to me.’ There was silence during which I merely waited. ‘And then I don’t want to.’ Shelley continued, now in a mumbling whisper, ‘I don’t want him to suffer’. Barely audible, ‘I know it’s wrong’. ‘What is wrong?’ I asked. ‘That I don’t want...revenge, but I should...after what he’s done.’


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Pause. I responded gently, ‘Do you have memories of him before it [the abuse] started?’ ‘No, I have no memories at all of before.’ ‘Is it possible that you might have had some good times with him prior to then?’ Pause. ‘Shelley,’ I said, ‘it is not uncommon for children, to care for as well as hate the person who has harmed them’. Pause. ‘Were you aware of that?’ ‘No.’ ‘Might it explain the conflicting emotions you experienced today?’ Shelley didn’t seek to hide her tears. She seemed comfortable to meet my eyes even though she was crying. The above interaction illustrates the importance of delineating the specifics of Shelley’s experience in this early session. Until we were both very clear as to what her specific issues were at that minute, we could not, really, have proceeded in any beneficial way. The intensity of Shelley’s distress made the process of enabling clarity particularly difficult. General principles of abuse-specific work n n n n n

A holistic approach Equality in transactions: avoid a power gradient Consistency and clarity help to build trust Facilitate the survivor’s control over the pace of work Foundations first, superstructure later

Pitfalls This section deals with aspects that are often areas of concern to a practitioner interested to take on abuse-specific work with their clients. It is divided into: • Managing risk • Survivor-related issues • Worker-related issues.

Managing risk Chapter 3 discussed types of risk, and assessing risk levels with a survivor. We will now consider how such information may be used to maintain your client’s safety during the process of abuse-specific work.


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Training and competence to manage different types of The overall principle in risk vary according to the worker’s professional background, managing risk is for a as well as their personal competence and experience in health worker to stay dealing with such risk. Capacity for risk management also within their duty of varies between service frameworks. In addition, each care according to their agency is geared differently to handle risk. training, competence The overall principle in managing risk is for a health level and service worker to stay within their duty of care according to their framework. training, competence level and service framework. Risk exceeding your competence should lead you to recruit additional help from suitably qualified professionals. Such a move need not, however, require you to stop your abuse-specific sessions with your client. It might merely involve working collaboratively on client safety with the recruited professional. Let us now look at what routine risk measures you could adopt in abuse-specific work. Managing risk requires you to: • gauge a survivor’s level of coping • facilitate coping strategies • devise safety protocols.

Gauging level of coping Chapter 3 described the need to gauge risk in your customary manner, in keeping with your professional training. We also noted that a survivor’s level of coping relates inversely to their risk level. In other words, the less a person is coping, the more they are at risk. At this stage of the process, it is useful to first establish what constitutes a ‘good’ level of coping for your client. What activities and tasks are they able to take on at such a time, and what activities are they unable to take on? One person might, for instance, describe a good level as one where they held a job, or were in a relationship, or maintained healthy routines with regard to eating patterns and exercise. They might, however, say that even at this level they are unable to have good sleep, and they also continue to experience some panic episodes. Allocate this coping level an arbitrary grading of 8 or 9, perhaps. Establish when the client last achieved this ‘good’ level of functioning and for what period they maintained it. Next, get your client to describe what they consider their worst level. Note its features. Grade this as 1 or 2 as the case may be. Establish when it last occurred. Now, grade with your client, their current level of coping between 10, an ideal best, and a worst case 1. Such a method of grading will give you and the client a ready-reckoner for use at various stages of abuse-specific work. It will prove particularly useful when gauging the optimal balance of exploration and containment required in early and ongoing abuse-specific work that will be discussed in Chapters 6 and 8.


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Other ways to gauge distress, such as recognising a certain bodily symptom as a distress indicator, could emerge in later stages of the work. This is discussed in Chapter 8 on ongoing abuse-specific work. Gauging level of coping What constitutes a ‘good’ level of coping for the person? n Identify its features. n When did they last experience it? n Give it an arbitrary grade close to 10. What are the features of their ‘worst’ level of coping? When did they experience it? n Give it an arbitrary grade close to 1. n

Grade the current level in relation to the above two levels

Facilitate coping strategies Coping strategies vary from one person to another. Strategies that are likely to succeed are generally those adapted from ones that have worked previously for your client. The holistic section of the assessment detailed your client’s special strengths. Subsequent early sessions give you a sense of how your client approaches everyday stresses. Now discuss what extra strategies your client might use to tackle current stress. For instance, one person might opt to return to the swimming activity they enjoyed as a child. Another, who might previously have used binge-eating as their method to cope, might volunteer a healthier modification of it. But, be realistic as well— substituting fruit for the familiar bag of crisps is going to test anyone’s willpower, and a distressed period is not the time to begin complex modifications. Chapter 3 discussed types of risk relevant to survivors. Suicide of a client is the ultimate worry for any health worker. However, several other forms of self-destructive and risk-taking behaviours are also important to stay mindful of—substance-use, or being accident-prone. Another client might act out; for example, get sacked from a job. There are many variations on the theme of self-sabotage. The risks associated with dissociation are often overlooked. We noted that dissociation is often a difficult symptom to identify. You would have identified your client’s risk-behaviour patterns in the assessment. Awareness of your client’s customary psychological mechanisms, too, is extremely useful. For instance, do they avoid issues? Do these issues build up eventually to a point where she/he acts in a sudden, impulsive manner? What form has this impulsive reaction taken in the past? Was it an outwardly expressed anger, or an internalised one that led to an act of self-harm?


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Having identified such behaviour and psychological sequences in advance allows both you and the client to be prepared in times of heightened distress. You know what danger signals to expect. This allows you to choose appropriate safety protocols to put in place.

Devise safety protocols You would have routine safety procedures within your service framework. Adhere to them. This section discusses a few additional strategies that you might consider useful in working with survivors. Safety protocols are best developed collaboratively and in a pro-active manner before they are needed urgently. Excepting of course, if your client is unable to be vigilant about their own safety—for instance, with increasing depression. Such an eventuality would require you to recruit appropriate skills unilaterally, such as from a local mental health team. Facilitating your client to eventually monitor and maintain their own safety is an important principle in all stages of abuse-specific work. The following steps could help: 1 Stay alert to a survivor’s reduced coping levels. • This allows an exploration of its current triggers and causes. • Which, in turn, allows the survivor to deal with such causes to the extent they are able. • It also allows you both to discuss what coping strategies could help. 2 Once you have decided on your client’s preferred coping strategies, you need to discuss safety protocols. These will depend on your training background and the framework of your service. It is useful to discuss these protocols prior to your client actually needing them. A non-hierarchical approach with your client is less likely to evoke the old feelings of helplessness your client experienced with their perpetrator. • Be clear as to what you can and can’t provide. You’ve already foreshadowed, in the plan outline, the possibility of needing to recruit additional help. Involve your client in deciding who or which agency this might be. • Use a step-by-step process with your client to identify appropriate local services they can contact—a local doctor or a mental health team, for instance, within work hours, as well as after hours when services are not easily accessible. This is especially important in the case of a socially isolated survivor. • Match safety protocols to the specific risk type. Protocols to deal with suicidal ideation, for instance, will not be the same as those for risk from substance-use. 3 Check coping levels periodically, particularly when the going seems tough for your client. Routine checks are an important safeguard. These tell you whether you are within your competence level, and alert you to the need to recruit additional help.


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Collaborative measures to maintain safety n n n n n

Be alert to reduced survivor coping levels. Identify current triggers and causes. Tackle current stressors. Devise coping strategies. Discuss safety protocols. – Match protocol to type of risk. – Be clear as to what you can and can’t provide. – Discuss who else to involve if needed.

Preparedness is half the battle. Such a discussion early in the process also reassures your client that recruiting additional help does not mean severing contact with you. The recruitment of additional expertise will not then feel as dislocating as it could otherwise. Remember that later complex abuse-specific work will only be possible if safety protocols are in place. Your client can only appreciate such a collaborative move, particularly if it helps them to continue in abuse-specific work with you.

Survivor-related issues This section deals with two aspects: • Intensity of a survivor’s need • Insight regarding problematic issues.

Intensity of a survivor’s need A survivor’s neediness is an aspect of abuse-specific work that many workers are inadequately prepared for. It often has a negative impact on the interactive process. We will consider, as examples, two hypothetical interactive sequences that are not uncommonly encountered in this field of work. • In the first situation, the survivor has clearly sought your help. You respond to their intense neediness with an extra emotional ‘giving’. Despite this, you sense ambivalence from them. You step up your ‘giving’ to the extent that you are caught up in your client’s agitation. You are confused by their continued unsatisfied need. The end result is one of frustration and withdrawal on your part; and on the survivor’s, a feeling of being rejected. Interactive sequence neediness within overt help-seeking Survivor seeks help conveys intense need shows ambivalence demonstrates unsatisfied needs becomes vulnerable and confused feels rejected and re-abused


Worker provides help is responsive puts in more effort loses objectivity is caught up in survivor’s agitation feels frustrated and withdraws

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The above sequence is avoided by maintaining objectivity within your empathetic stance. It enables you to stay helpful without getting caught up in your client’s turbulence. • The second type of sequence is one where a survivor has not clearly sought your help. They might be a friend, or a co-worker, perhaps. This is not a far-fetched possibility, given that people with past trauma often have special strengths and personal qualities that suit certain fields of work. In this situation, you might sense a vulnerability in the person. It evokes a supportive response in you. You become closer and eventually they reveal parts of their traumatic life story to you. A special friendship develops; one compounded by issues of privacy/secrecy. The person is emotionally needy, and gradually you drift into taking on a helper role. The increasing closeness, however, triggers their habitual distrust and ambivalence in such close emotional situations, and you are caught up in their cycle of responses. Interactive sequence neediness within covert help-seeking Survivor mutual connection in shared activity discloses past trauma in confidence secrecy contributes to the dynamics interaction becomes distorted becomes more openly needy neediness remains unsatisfied feels rejected, shows ambivalence

Colleague/friend perceives vulnerability relationship changes ‘gives’ more interaction becomes distorted takes on helper role becomes frustrated & resentful withdraws

What would help here is for you to stay aware of relevant issues. This would allow you to make deliberate choices regarding your side of the interaction. Your objectivity enables you to consider options to help without getting inappropriately entangled in complex interpersonal dynamics with a work colleague. Interpersonal dynamics are discussed further in Chapters 6 and 8 on early and ongoing abuse-specific work.

Insight regarding problematic issues Abuse-specific work discussed in this chapter, as well as in Chapters 6 and 8 on early and ongoing work requires a survivor to have a degree of insight. By this, I mean the survivor needs to be aware that they have problematic issues in the way they function; not merely the fact that they need abuse-specific help. Insight in this context does not need a survivor to be highly psychologically sophisticated as to their personal and interactive dynamics—only that they be aware of problem issues and actively seek to change them. In other words, they would need to have taken ownership of such problems. This is an important consideration. It distinguishes such a survivor of abuse from a perpetrator. As noted previously, perpetrators—who undoubtedly might be past


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victims of childhood abuse—may not take responsibility for their own behaviour. Effective programs for perpetrators require external controls and monitoring processes that are quite different to the insight-based strategies described in this book. Further aspects of insight are discussed in Chapter 7.

Worker-related issues Practitioners undertaking abuse-specific work need to be aware of a range of responses it could evoke in them—anxiety perhaps being the most common. What might they uncover for the client? Would the worker be able to handle the developing situation?—these are not uncommon concerns. These concerns could stop some practitioners from entering the process. Others, feeling a need to do something tangible, might focus entirely on the survivor’s current symptoms such as depression. Fears for client safety are, as we noted, often the reason for a worker to refer their client on to another practitioner who might not handle abuse-specific issues. Conversely, some practitioners believe they ‘owe’ a survivor special consideration because of their trauma. This could arise from a view that others do not understand the survivor as well as they do. Unfortunately this is an attitude that might lead to their taking on just that little bit extra, beyond their level of competence or framework. For any worker, whether in an agency or in sole practice, the intense nature of abuse-specific work as well as survivor neediness, ambivalence and distress can be hugely draining. The long-term risk of cynicism and burnout is very real. Workplace routines of peer review, supervision, and clear policy go a long way to handling these issues. Throughout the process of abuse-specific work, a worker needs to remain clear as to what their professional training allows them to take on. Such clarity reduces potential complications. Although taking on a saviour role may feel rewarding in the short term, it can only add up in the long run to increased risk. Collaborating with suitably qualified colleagues, when you recognise complexity that is outside your framework or level of competence, is the wiser position. And finally, it is not uncommon for people who have experienced trauma and abuse in their own life story to be attracted to take up this work. Chapter 5 will discuss resilience, and the strengths that evolve from successfully overcoming hardship and trauma. Such workers will need to stay alert to re-activating their own anxiety and distress when providing abuse-specific work to others. This said, such workers also bring special strengths to the work. Worker issues pertaining specifically to early and ongoing abuse-specific work are discussed in Chapters 6 and 8.


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CHAPTER 5

Underpinnings of early abuse-specific work CHAPTER AT A GLANCE The powerlessness package The assertiveness–anger package The intimacy package The insight package The resilience package

As stated previously, abuse-specific work is complex. This book divides it into early, and ongoing work. Each is based on aspects of mental health issues experienced by adult survivors. Early abuse-specific work is based largely on a survivor’s emotional and behaviour aftermath, while ongoing abuse-specific work takes into account a mental illness aftermath. Having explored the overall principles of abuse-specific work as well as pitfalls in Chapter 4, you probably expected to have proceeded to strategies and techniques by now. But there is just a little more groundwork to cover. We need to discuss the rationale for the strategies and techniques to be used in early abuse-specific work. To recap, Chapter 1 gave an overview of the adult health aftermath of childhood sexual abuse. This included its mental health components. We will now explore in further detail, some combinations of emotions and behaviours that are commonly experienced by survivors. Discussed here as ‘packages’, these will provide the rationale for the strategies and techniques especially useful in early abuse-specific work to be described in Chapter 6. It is important to regard such combinations of emotions and behaviour merely as a tool to aid your work. Links between the various ‘packages’ can be just as important for a particular survivor. Also, the list selected for discussion in this chapter is by no means exhaustive. The selection aims to provide you with a template for use with specific issues of individual clients.


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The powerlessness package A feeling of being powerless often underpins a survivor’s depression, anxiety or other health issue that leads to their seeking your assistance. Let us examine some of its components.

Self-confidence and self-esteem Lowered self-esteem and self-confidence may cause survivors to defer to others at work, socially, or in an intimate relationship. Considering their own intuition and judgement to be inferior, the survivor may place even personal decisions into the hands of others. Patronising responses and put-downs that follow, maintain a vicious cycle. ‘Cath’ had been subjected to physical violence as a child, and was later teased and bullied at school. Overeating, an early coping strategy, led to being overweight, which added to her problems with self-esteem. Cath left school at the end of Year 10, convinced that she was less intelligent than her peers. Neither her later return to successful study, nor her remarkable career progress had reversed her low self-esteem. Cath’s low self-esteem was not overtly apparent. None of her work colleagues, for instance, guessed how easily her confidence was shaken. She spent hours perfecting each work report she wrote—partly so that her boss would not fault them, and partly for praise. The slightest hint of displeasure or criticism could depress her for days.

Guilt, shame and self-blame Why does an abused child feel guilty when they have done nothing wrong? Guilt and self-blame may derive partly from the abuser’s attitude or words: ‘You’ve caused this’; ‘You want this’. It could also relate to a survivor’s later self-questioning, especially one whose sexual …shame is generally abuse began or continued into puberty: ‘Why did I not stop linked to external it once I knew it was wrong?’ Such a survivor might attribute judgement; guilt, to an the abuse to their own heightened pubertal sexuality, rather internal one. than to the abuser’s power and responsibility. In a situation of incest, a child could also feel guilt towards their non-abusive parent, or towards a sibling who was not ‘special’ and consequently bore the brunt of the abuser’s negativity. We often use the word shame interchangeably with guilt, sometimes even using the term ‘guilt-and-shame’ as though it were a single entity. However, there is a difference: shame is generally linked to external judgement; guilt, to an internal one. Survivors often date their sense of shame to when their awareness of social norms and taboos began to develop. Some describe their initial experience of shame as


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linked to their first disclosure of abuse to another person. Responses and attitudes they encounter, such as denial, disbelief, or even blame contribute to their sense of shame. Guilt, by contrast, seems to predate first disclosure. ‘Miranda’ always thought there was something dreadfully wrong with her, that Uncle Phil, her father’s best mate, should like her in a certain way. Although she had always blamed herself for what Uncle Phil did to her when she was eight years old, she only experienced shame as a distinct emotion after she told her mother in adolescence. ‘Don’t tell your father,’ had been her mother’s response, ‘It will kill him’. Miranda took the response to indicate that the main issue, really, was what others would think. She did not tell anyone again until her mid-30s, when she identified shame as her major barrier to seeking help. Guilt and shame experienced by an abused child continue into adult life causing survivors to assume blame inappropriately—not only for their childhood abuse, but for many ongoing adult interactions. Self-blame hinders a person’s objectivity and capacity to evaluate others.

Secrecy, stigma and isolation Chapter 1 noted that secrecy related to childhood sexual abuse sets it apart from other forms of trauma. Such secrecy could be one imposed by the perpetrator during the survivor’s childhood. At a later age, however, social stigma plays a significant part in a survivor’s maintained secrecy. Despite considerable societal change regarding sexual norms, childhood sexual abuse continues to be associated with social stigma. An abused child often uses social withdrawal as a coping strategy. This withdrawal, continued into adolescent years, hinders the learning of crucial interpersonal skills. Prolonged use of a personal trait of maintaining secrecy might then extend to other non-stigmatised aspects of life. Such an adult consequently functions in an isolated internal landscape that is inordinately coloured by guilt, self-blame and, possibly, the perpetrator’s version of events. Ordinary external reality checks that non-abused others take for granted might not be possible for such a person. This, in turn, impairs such a person’s ability to negotiate effectively—an ability that is essential in everyday living. Such issues may not be apparent to a survivor at the point of seeking help for adult health problems. They might only emerge over a period of abuse-specific work. ‘Elaine’, a second-year university student sought help for nightmares. She put them down to recently beginning her first sexual relationship. This seemed to have opened up a Pandora’s box of emotions. Life, she said, had previously been fairly unremarkable. She described herself as a quiet child, who spent her leisure hours reading. She seldom made close friends and had few extracurricular interests. But this had not


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generated too much concern in the family, as her academic prowess more than made up for it. Only after many weeks in therapy, with some relief from her symptoms of anxiety and dissociation, was Elaine able to speak further about her childhood abuse by her maternal grandfather. Her main strategy to cope had been a mental mechanism to ‘disappear during his touch’. She had not sought help for it previously partly because her one attempt to tell her mother hadn’t been heard. Elaine also mentioned that her mother was financially and emotionally dependent on the grandfather. Therapy allowed Elaine the space to work out her strengths, coping strategies and limitations. The dissociative mechanism of ‘disappearing during his touch’ had been her immediate protective response in childhood. Withdrawal and isolation had provided additional means of escape. Her numerous hours spent reading and studying were strategies to achieve social isolation. The ongoing abuse had made Elaine feel something was very wrong or bad about her; and consequently, she could never have friends. Academic success became the more achievable alternative giving her the sense that at least she was good at something.

Difficulty in gauging personal risk and safety Isolation and lack of a social network can make a survivor vulnerable to people with ‘predator’ type characteristics. Despite their abuse-experience, they might credit others with generally doing the right thing or, at least, not intending harm. Such a misconstruction is in keeping with a need to view only the silver lining, and helps to sustain hope for a brighter future. Even survivors who do not trust easily may have problems in gauging personal risk and safety. ‘Kate’ was a 25-year-old artist who lived on the poverty line. She moved from one meagre dwelling to another. Others had cautioned her about living alone above an isolated factory, but for Kate, affordable studio space outweighed the risk. Events led to a termination of her lease and, once again, Kate faced the prospect of moving. She cleaned and scrubbed walls and floor, ‘doing the right thing’ to leave the place in a better condition than when she arrived. The landlord hovered daily but offered no help with her solitary removal of belongings into a ute with no assistance from friends or family. On the final day, he flippantly suggested that she might find use for some industrial machinery that had been in the yard since before her tenancy. When she refused, he suggested that she might dump it in the tip, to which she replied that it was too heavy for her ute. To avoid further confrontation Kate pretended an urgent errand and left, proud of her assertive stance. On her return however, she found the heavy machinery loaded on to her ute. Feeling


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utterly helpless she drove to a metal-recyclist but could get no assistance to unload. Three days later, the machinery was still in the back of the ute. Kate had placed a higher priority on having a suitable art space than on personal risk. Her requirement from herself ‘to do the right thing’ by others far exceeded what she expected from them. She didn’t consider the landlord’s unscrupulous act as trespass, or as infringing on her rights, either.

The assertiveness–anger package Inadequate assertiveness, and anger turned on themselves in the form of depression and self-harm is a not uncommon reason for a survivor to seek healthcare. It is useful to regard assertiveness and anger as part of a personal continuum; inadequate assertiveness inevitably leading to frustration and anger.

Assertiveness Impaired assertiveness often follows from the lowered self-confidence and self-esteem discussed earlier. Such impairment could be evident in work, home or social settings. ‘Lynn’, who had experienced childhood abuse, had great difficulty being assertive at work. She always got the worst tasks and the least popular shifts. After tolerating unfairness for varying lengths of time she would periodically explode with hurt and anger. This earned her the reputation of being unpredictable and short tempered. There were jokes about her ‘time of the month’. Lynn, too, attributed her outbursts to her menstrual cycle.

Experiencing anger Anger is a self-protective emotion. It allows us to recognise unfairness and injustices that we incur at the hands of others. Many survivors may find it difficult to feel anger. The reasons are complex. For instance, their family and social conditioning might have encouraged the view that anger is ‘bad’. Another reason might be an inadequate awareness of personal rights. Irrespective of its origins, such a difficulty to experience anger disadvantages the survivor. ‘Elsie’ had been in therapy for about a year when she remarked, that she’d got ‘pissed off’ with Adrian, a colleague, who ‘told her off’ about the time she took to recount an anecdote. ‘So what?’ Elsie retorted. This was remarkable for Elsie. Previously, she would have been devastated by his put-down, and gone completely silent. Elsie said she could not recall ever feeling angry. She had often experienced hurt or distress, but never anger. She inevitably did more than her share at work, perceiving the unspoken needs of colleagues who took her goodwill for granted.


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Expressing anger Experiencing anger and expressing it are not one and the same thing. When we react with angry words or behaviour to an incident we are expressing—externalising—our anger. We may, on the other hand, choose to curb our anger for a period, to deal better with the incident. Here we are exerting a choice as to when and how we will externalise our anger. The outcome, however, of an immediate and direct expression of anger tends generally to be counterproductive to us. Optimal and constructive channelling of anger requires us to have appropriate strategies. Survivors may have difficulty in expressing anger constructively; many develop unhealthy, self-destructive ways. They may turn anger in on themselves. The following example illustrates a difficulty with feeling anger, as well as with externalising it. ‘Trish’s’ forearms and legs were criss-crossed with scars from numerous selfinflicted acts. She described her emotion at these moments as not anger, but an intensely distressing sensation—as though she was ‘about to disappear’. Her only relief from this emotion came from cutting herself with a blade. The pain of the gash and a warm sensation of blood helped ease her intolerable sensation. Trish was in abuse-specific work for a considerable while before we were able to decipher her emotional sequence during such times. Events that would previously have triggered the ‘disappearing sensation’ now provoked anger. Trish then began to recognise the extent of her previous difficulty to experience anger. In other words, when she was able to feel more legitimate about her anger, she did not need to ‘disappear’. The benefit from this insight was that she gradually began to self-harm less.

Difficulty to confront Another component of the assertiveness–anger package is a survivor’s difficulty to confront others. This often stems from childhood feelings of powerlessness, particularly if abuse occurred within the family. Such a child often adopts a strategy of seeking to please or appease others in difficult situations. Appeasing may be the only recourse for a child who fears that conflict or confrontation could lead to rejection and, consequently, loss of even this minimal security. Maintaining a known, albeit, abusive security may seem preferable to an unknown future with no security at all. The pattern then continues into adult life. ‘Linda’ would often say she did not know ‘who’ she was, or what her likes and dislikes were. Linda had grown up in fear of a father, who she recalled as angry most of her childhood. He was physically violent towards her brothers, who, in turn, abused her sexually. She described her adult relationships with men as


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‘disastrous’. The more she did for her boyfriends, the more they expected from her. Many of them were angry men like her father. She felt as though she had spent most of her life trying to please people. She felt totally unable to confront others. When confrontation occurred between others in her presence, Linda felt compelled to take the role of peacemaker.

Difficulty with being direct An inability to confront another person often causes a distressed adult survivor to turn to a third person for help. The new person becomes the confidant and saviour, and the previous interaction or friendship, unsatisfactory in the survivor’s view. This aspect can become particularly relevant in abuse-specific work. Intense neediness of some severely traumatised survivors could be inadequately met by a single helper. Sometimes a series of helping people, or agencies, become involved. Over a period of time, helpers could become critical of each other largely because of the survivor’s inability to be direct regarding their unmet needs from each. ‘Fiona’, who had a background of childhood abuse, was often suicidal and sought urgent help. Her intensity of despair and degree of neediness were clearly apparent at such times. Fiona had an appealing, dependent manner that made her health workers feel for her immediately. That she was unable to state negatives directly emerged only later. When her needs were unmet at one agency Fiona sought help from another, expressing there, her dissatisfaction with the first. The second agency, considering itself better able to help Fiona in a ‘real’ way, became critical of the first. This ‘splitting’ dynamic also tended, over time, to occur between workers within an agency. Eventually, Fiona came to be regarded as manipulative in each setting, which only increased her sense of alienation and sabotaged the support and caring she urgently needed. A survivor’s difficulty to be direct and their counterproductive behaviour can be addressed collaboratively if regarded by all concerned parties as an outcome of the scale of the survivor’s neediness. This will be discussed further in Chapter 8 in the context of ongoing abuse-specific work.

The intimacy package Issues within relationships are another common reason for a survivor to seek help from a health professional. Trust issues, personal boundaries, and sexuality are aspects of this. For any one of us, day-to-day interactions vary according to the nature of our relationship with the other person: whether they are a friend, relative, intimate partner, mentor, spiritual guide, educator, counsellor or therapist. Interactions with a colleague, for instance, will differ from those with an intimate partner.


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Factors such as trust, the degree of closeness and the power balance in a particular interaction have a bearing on personal boundaries we maintain. Such considerations are also relevant to abuse-specific work. Professional misconduct is, unfortunately, not uncommon in this field of work. The issue of boundary blurring in such a situation will be discussed in Chapter 8.

Confusion and ambivalence regarding trust Most people tend to associate abuse with acts of violence. Abuse in childhood, however, could occur in a seemingly caring context. This is an aspect that generates much confusion in the mind of a child, and is a confusion that could continue into adult life. ‘Jenny’ was sexually abused by her father. The abuse began when she was approximately seven. He often told her she was his favourite daughter and that theirs was a ‘special’ relationship. Jenny later recalled that she felt deeply for the loneliness she perceived in her father at the time. Because his sexual acts were not accompanied by anger or violence, Jenny had not defined them as aggression even though her experience of physical pain did not match her father’s misleading words. Later, as a more aware adult, Jenny went through several emotional processes. She had to re-label her understanding of the situation. What she had previously considered good/positive in her father’s behaviour had to be re-labelled as bad/negative. She also tried to stop caring for her father. She had to create an emotional distance from the ‘special’ caring. These processes had a significant impact upon Jenny’s adult friendships and intimate relationships. A young child cannot detect falsehood in statements and behaviour of a trusted abuser. Such ‘seductive abuse’ with special privileges causes much confusion and ambivalence in a survivor’s adult years. The confusion could lead to wide fluctuations of trust in a close relationship. As adults, we generally foster closeness with another person on the basis of a perception that we care for the person, who reciprocates. Feeling close is accompanied by a view that the other is ‘good for me’. Survivors of seductive abuse may later find it difficult to differentiate between what is good for them in a relationship, and what is not. They may, in addition, be attracted to a certain ‘special’ caring that is reminiscent of the abuser’s in childhood. They could also regard the relationship as exceedingly positive and ‘good’ at one time, but very negative and ‘bad’ at other times. Other survivors might remain continuously ambivalent about a relationship that repeats elements of the abusive relationship of childhood.


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Unclear personal boundaries Survivors of childhood sexual abuse might have great difficulty in maintaining a healthy personal space. This is not surprising in the light of their childhood experience. As was discussed in the previous section with regard to trust, a child’s personal boundary is violated in abuse. Often, the perpetrator is a trusted adult. The child, lacking an awareness of social norms and taboos, does not have any reason to see this as intrusion into their personal space. The intrusive situation becomes this child’s norm—it forms her/his construct of personal space and boundaries. Later, when she/he becomes aware of its unacceptable nature, the construct will need to be corrected. Such a correction is a consciously implemented one. It then becomes understandable that an adult survivor of abuse might have ongoing difficulty in staying alert to slippages in personal boundaries and maintaining a healthy space. Lack of vigilance regarding personal boundaries often leads to blurred boundaries and a feeling of powerlessness in the longer term. This might occur for a survivor at work, socially, or in intimate relationships.

Awareness of own boundaries It is in intimate relationships that maintaining personal boundaries assumes the most complexity for survivors. The balance between maintaining personal space and adjusting to a partner is unique to each relationship. Each partner adjusts, either consciously or instinctively, to their own, as well as to the other’s need for space. A successful balance contributes to maintaining a healthy relationship. A survivor might initially welcome or consider expedient, certain behaviours from the other person. Even if their initial response were negative, they might tolerate the behaviour as a necessary adjustment to the relationship. ‘Josie’ admired her partner ‘Rick’s’ neat and methodical approach to things. Her untidiness was often the butt of his jokes. It was not until Rick undertook a project to organise all her childhood photographs that Josie began to have misgivings. Her previous higgledy-piggledy albums were discarded. As Rick re-arranged the photographs chronologically, wrote dates neatly beneath each, in albums selected for themes, Josie found herself becoming increasingly resentful. She said that Rick’s habit of tidying her work papers for her each week was also beginning to jar. Although she had never requested this, she’d initially considered it as very caring. She then began to notice that he made comments that corrected and advised her on topics that she knew better than him. In retrospect, Josie began to regard Rick’s initial offer as intrusive. She now considered his manner as often patronising. She remarked that she could see him adopt it with others as well.


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For a survivor whose childhood personal space was violated by a loved person, ‘being intruded upon’ and caring might go hand in hand in adult relationships. A survivor might feel incredibly helpless without the relationship. Emotional dependence on the partner hinders objectivity. ‘Tara’ had been ‘interfered with’ by her grandfather until the age of 7 years. Tara described the incident where Grandma ‘caught him out’, but then yelled at both Tara and Grandpa. Grandfather stopped the behaviour. However, Tara’s Dad started soon after. Tara remained confused about her Dad’s behaviour for years. She felt unable to blame him as clearly as she did, her grandfather. Tara left home at the age of 16. She could not seem to stay very long at any of her jobs. She would start to panic after a few weeks in each, and leave. Then she met Tom who seemed to understand her. He too had been abused in childhood. They talked for hours about her problems. There was nothing she did not discuss with Tom. He came up with strategies for each stressful situation. She was no longer in a constant state of panic. Tara became more confident in her then current supermarket job. Tom convinced her that she should not be seeing her old friends who were all ‘users’. She felt looked after and protected. Then things started to happen to her cat. Someone was playing cruel tricks. Tom suggested it was a previous boyfriend. Tara began to panic again, but still believed that Tom would protect her. She started to get nasty phone calls. The man called her awful names, and threatened to ‘get her’. She turned to Tom even more. He consoled her, told her he would look after her always. Tara feared she was going mad and that there would be no escape. Only many years after the relationship ended did Tara piece together these and other incidents to come to the view that Tom had been responsible.

Sexuality Survivors of childhood sexual abuse may have a range of sexual issues in adult life. Not uncommon, is a difficulty to disentangle feelings of affection from sexual behaviour. The survivor might demonstrate their feelings of affection for a person in a sexual manner. It is as though a sexual act were the natural outcome of the affectionate feeling. This might not be a consciously thought out sequence for such a person; merely that the emotion and behaviour go hand in hand. Not uncommon, The association derives from the survivor’s childhood is a difficulty to experience—for instance, in incest where affection and disentangle feelings sexualised behaviour were linked. We have previously of affection from noted the confusion that seductive abuse generates in the sexual behaviour. mind of the child. Such confusion could continue into adult


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life even after the survivor has logically differentiated the two. A survivor may ‘sleep around’ for many young adult years in search of affection. Survivors of sexual abuse may also have difficulty in knowing their own sexual needs. Compliance with another’s sexual desire might be far easier than trying to gauge their own desire. It is an aspect of relationships that causes insecurity and distress. For some, sex is totally determined by the partner’s urges. Others are unable to say no. Yet others dissociate in the sexual act. Some, unsure about their other capabilities, may use sex as a way to earn a livelihood.

Re-enactment Adult survivors are susceptible to re-enacting their childhood abusive experience without realising that they are doing so. Although this could occur in any type of ongoing interactions involving authority and power, intimate relationships are particularly susceptible to such re-enactment. Survivors might be drawn to people similar to the grown-ups of their childhood. Alternatively, they could be attracted to people with a similar vulnerability to theirs. Either situation lends itself to a replay of childhood issues. The significant ‘other’ may be prone to denying responsibility, as did the perpetrator in their childhood, triggering for the survivor old, familiar responses such as self-blame. Several issues make it difficult for a survivor to identify and correctly name the relationship as an abusive one. They might view the partner filtered more through their own hope for love and caring rather than tempered by the reality of the person’s actions. Or, a violent act may be explained away as, ‘He only did it out of jealousy’, and ‘Jealousy means he cares a lot’. Alternatively, the survivor is acutely aware of the partner’s needs, and not of their own—‘He was abused as a child himself, so I should show understanding’ for instance; or, ‘He does not mean to [do it]’. ‘Paula’, who was 31 years old, knew that she was being treated badly by Sam, her boyfriend. She helped him with his studies, supported him during his depressive periods and lent him money. He never returned the money, was unheeding of her life stresses and had other sexual partners. Paula had experienced much childhood violence, but recognised and articulated it as such only in her late teenage years. She considered herself unattractive and unlovable until she met Sam who said he loved her. She had never thought such a wonderful thing could happen to her. It made her particularly sympathetic towards his exceedingly traumatic childhood. Because she ‘understood’ his childhood suffering, Paula did not set limits on Sam’s current behaviour. Her ‘understanding’ required her to condone even his treatment of her. He ‘couldn’t help it’. His trauma was to blame, not him. In the closed and secret unit of their relationship, she carried the burden of his childhood trauma. Paula often expressed sentiments such as: ‘If I give him the security that he


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never had in childhood, he will change’; ‘He doesn’t mean to behave the way he does’; ‘If I continue to love him unconditionally, he will never behave with me, as he did with previous girlfriends’. Given that in society privacy is central to intimacy, violence and abuse within adult relationships are likely to remain hidden. Society generally considers domestic situations to be the private business of the persons involved. Other people in the survivor’s life, even if they are aware of violence, might not intervene. Another situation of re-enactment is relevant to abuse-specific work. Long-term therapeutic alliances such as those within counselling or psychotherapy—intense exchanges subject to norms of confidentiality—can re-enact abusive elements of a survivor’s childhood. Professional misconduct that breaches sexual boundaries of a client may begin by being regarded by one, or both parties, as a form of special caring. What was previously merely a confidential professional transaction then turns to secrecy. For the survivor, self-blame and other familiar behaviour patterns of childhood are triggered. The betrayal of trust, so reminiscent of childhood, escalates the survivor’s sense of powerlessness. The power imbalance inherent in practitioner–client interactions, as well as the survivor’s lack of social resources, makes it difficult for them to seek outside help, or to make a complaint.

The insight package The central premise for abuse-specific help described in this book is that the health practitioner is responding to a survivor who has sought help for health issues that they consider to be related to their childhood abuse. When a survivor takes the initiative to seek help, they are most likely to: • be aware that they have problem issues, and also • be taking responsibility to work on these. Both aspects are prerequisites for the abuse-specific strategies and techniques to be described in Chapters 6 and 8.

Internal limit-setting Survivors of childhood abuse often have harsh internal criteria for themselves. As noted earlier in this chapter, many experience inappropriate self-blame and guilt. They may set standards for their own behaviour such as, ‘I should never hurt someone else, because I know how horrible it is to be hurt’ or ‘I will never stoop to…’ (irrespective of how another person treats them). As we noted, perpetrators, by contrast, generally lack such capacity for internal limit-setting and require others to set restrictions on their behaviour. They try to get their own needs met unless stopped from doing so. They may also justify their own actions or attempt to mislead others by faulty descriptions of their behaviour—for instance, the sexual act being described to the child as an act of special caring. Such


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‘talking-up’, or grooming/bribing behaviour may not only pass as socially acceptable, but even earn praise from others. This difference throws light on why a relationship between a person with excessive internal limit-setting and one with deficient limit-setting is likely to turn disastrous. A capacity for internal limit-setting is essential for early as well as ongoing abusespecific work to be discussed in Chapters 6 and 8.

Motivation Abuse-specific work, as described in this book, requires a survivor to be particularly motivated. At initial presentation, a survivor who feels overwhelmed and helpless might regard their role as one of being a recipient of your expertise. However, once the assessment and goal-setting process is accomplished, a fuzzy idea of ‘HELP’ is no longer applicable. Both you and the survivor are by this stage more knowledgeable as to the specific tasks that lie ahead. The process you’ve undertaken together has also enabled you to spell out what you, the practitioner, are able to contribute towards these tasks. Of course, the survivor cannot know the technicalities of what lies ahead. What she contributes at this stage is a preparedness to put in the effort. A survivor’s motivation is essential for the work to be described in the next few chapters. You can only contribute your end of the joint tasks. Remember, if at this, or any stage of the work, a survivor’s depression or anxiety becomes overwhelming, this will need to take priority. But once the symptoms are under control, it will be necessary to return to the abuse-specific work plan.

Awareness of others’ boundaries Like many other aspects of interactions, mindfulness of another’s personal space is learnt in childhood. Undoubtedly, this varies between people; some will be more aware than others. Awareness of another’s boundary also varies with our intensity of emotional need at a particular time. In times of greater need we might give less importance to the issue of another’s space. However, others are likely to tolerate only a certain amount of such disregard. ‘Jeremy’, who was 20 years old, had led an isolated life without a significant social peer group. Recent nightmares had brought back memories of abuse by his grandfather at the age of nine. He began to speak about it to a work colleague who had struck him as ‘kind’. They had several conversations after which she gave him her home telephone number. They had several further phone conversations of increasing length. The colleague became alarmed at Jeremy’s intensity and put a stop to the phone calls. Feeling increasingly desperate in his need to talk, Jeremy kept trying, but now encountered an answering machine. Driven by panic, he


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arrived at her front door one day, and rang the bell. She was horrified at finding him on her doorstep and called the police. Jeremy was devastated. He had not considered the implications of his persistence after she had clearly told him to stop contacting her. He did not respect her space. In his agitation, he had not perceived the woman’s growing fear of him. It is to be noted that a perpetrator’s disregard for their victim’s personal boundaries assumes key relevance for perpetrator treatment programs.

The resilience package It is a common observation that people who have coped with hardship often have strengths beyond those available to others. This could be particularly true of survivors of childhood abuse who have found ways to cope with ongoing adversity. Many, however, continue to use coping techniques and strategies they have used since childhood. This tends to be energy consuming because childhood options are not the most appropriate ones in adult life. Because the survivor has not had the opportunity Seen in this light, to develop a range of sophisticated strategies suited to a survivor’s coping complex adult needs, they overuse the ones they do have. behaviours signify In other words, they function within their childhood level of tenacity in overcoming emotional resources. adversity, even Seen in this light, a survivor’s coping behaviours signify if the methods tenacity in overcoming adversity, even if the methods are are insufficiently insufficiently sophisticated. These behaviours should be sophisticated. considered as a faulty application of a learnt process rather than as ‘manipulative behaviour’ or a ‘chemical imbalance’— descriptions often used by others. Familiar, already mastered strategies provide a solid starting point in abusespecific work. Further work will build on these, and aim to facilitate a survivor to acquire a range of strategies appropriate for complex adult issues. To this end it is often easier to help a survivor to adapt their old strategies rather than to learn an entirely new range of behaviours.


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CHAPTER 6

Strategies and techniques in early abuse-specific work CHAPTER AT A GLANCE Aims of early abuse-specific work Principles of early abuse-specific work Content of early sessions Strategies in early abuse-specific work Techniques in early abuse-specific work Worker-related issues in early abuse-specific work

An important goal of early abuse-specific work is to enable a survivor to acquire a deeper understanding of how their childhood abuse has affected their functioning over the years. This will allow the person to work out ramifications of the problem issues they raised in the initial assessment process. The new mind–body awareness that emerges from such a process enables the survivor to devise new ways to handle the consequences of abuse on their emotional and physical health. Chapter 4 discussed the overall principles and processes of abuse-specific work with survivors. We will now consider principles, strategies and techniques especially useful in early stages of such work.

Aims of early abuse-specific work For a survivor to work on understanding the impact of their abuse on various aspects of their life you will, together, need to first achieve a safe interpersonal space where they can speak of abuse-related issues. Speaking at length about abuse-related issues in a safe, empathetic yet objective environment allows the survivor to explore the complexities of these issues. Deeper understanding will allow the survivor to improve their coping skills and level of functioning.


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Aims of early work n

n

n

To develop a safe interpersonal space for the survivor to explore the complex impact of their abuse To help the survivor to gain a deeper understanding of abuse on their health and functioning To help the survivor to develop more appropriate coping skills

Principles of early abuse-specific work General principles of abuse-specific work were discussed in Chapter 4. Review these if needed. Here, we will cover only principles central to early stages of work. Early work needs you to shore up the foundations we discussed in Chapter 4; especially those pertaining to trust. Remember developing trust takes time. A survivor will eventually need to feel secure in the interpersonal environment you are creating together. Consistent and Clarity and equal interactions between you and your client promote transparency of this goal. transactions are Clarity and transparency of transactions are particularly particularly important important at this stage. Your client needs to be clear about at this stage. what you have said, and why, as well as the reasons for your interactive stance. Explain things as you go. Don’t assume they know your rationale. It goes without saying that you will need to be clear yourself about why you are saying or doing something. Also stay very aware of interpersonal transactions. Staying aware of pitfalls with regards to overt and covert interpersonal dynamics—some examples of which were discussed in Chapter 4—will help you. And finally, stay attuned to safety and risk issues discussed previously. Principles in early work n n

n n

Allow time for trust to develop. Shore up foundations of interpersonal space: – e.g. ensure consistency and equality in interaction – aim at clarity and transparency of transactions. Be mindful of pitfalls in interactive dynamics. Maintain safety and continue to monitor risk.

Content of early sessions As noted previously, a survivor might not start speaking immediately about their abuse. They might prefer instead to talk about day-to-day stressors. However, if one of the items in your initial goal plan was for the survivor to speak about abuse, this needs to eventually begin.


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Disclosure work Just to remind ourselves, ‘disclosure’ is generally understood in this field of work, as a survivor communicating the fact of their abuse to another person. I use the term ‘disclosure work’ to include dealing with its ripple effect. Speaking about their past abuse could generate some issues for the survivor. The telling of their traumatic story might have an impact on the survivor. Not every survivor feels immediate relief upon unburdening themselves of a long-held secret. Some surivors experience a temporary increase of distress, or worsened symptoms— not surprising, given that previously unexamined material is now hung out in the clear light of day, so to speak. Part of disclosure work is an appropriate handling of this ripple effect. It helps for a survivor to be prepared for this eventuality. Being prepared for worsened symptoms helps the survivor to handle what could otherwise be a very confusing and distressing time. ‘Leah’, who was 22, had suffered from asthma since childhood. She had several recent episodes requiring admissions to hospital. During one such admission she told the nurse in intensive care that she’d been sexually abused in childhood. This eventually led to her referral to me. Leah said that she’d started to remember her abuse only in the previous few months. She described much fear and anxiety at the memory fragments. They did not make sense and evoked strange body sensations. At times she felt a sharp pain in the anal area, while at other times she felt as though a person’s hands were on her shoulders, holding her immobile from behind. The memories had triggered the combination of asthma attacks and panic that had brought her into hospital. At the limit of her tolerance, and sensing a caring response in the intensive care nurse, she decided to speak. Leah’s panic escalated after her disclosure. She also became depressed, with suicidal thoughts. Her unstable asthma prolonged her stay in hospital. Over the next couple of weeks in the ward, Leah remembered further abuse details. The fact that she felt secure in hospital allowed her to process her memories—to try and make sense of them. The sharp pain, she eventually thought, was that caused by her stepfather’s penis. She would have been about five at the time. Some months later, Leah pondered on the reason for her worsened symptoms at the time of disclosure. ‘Because you can no longer pretend it hadn’t happened’, she said insightfully. The ripple effect of disclosure varies from one person to the next. You will need to handle each situation with appropriately matched strategies and techniques, as discussed later in this chapter.


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Stay mindful that active probing at this stage risks triggering the survivor’s sense of powerlessness. Your initial assessment process has already given you the basic information—who the perpetrator was; the survivor’s relationship with them; and perhaps a rough idea of the survivor’s age at the onset of the abuse; the frequency of abuse and; when it ended. What the survivor needs at this stage, is your time, empathetic listening and validation. Further details will emerge, if relevant, with time. A spontaneously evolving disclosure-process impacts on the survivor quite differently from one in which she is required to answer abuse-related questions put to her by another person. In a self-determined pace, emerging material is likely to instinctively occur in a sequence that allows better coping. Disclosure work in a survivor-paced process will consequently vary from one person to the next, as well as for a person over time.

First disclosure A brief digression is warranted at this point to consider a legal issue. ‘First disclosure’ is a term used to convey the added information that the survivor has not told anyone previously. The term is one of special significance in a justice setting where, for example, it could be significant that a 28-year old who has taken her stepfather to court made her ‘first disclosure’ to her best friend at the age of eleven rather than to you, two years ago. While all healthcare record-keeping needs to be meticulous, do take care to notate a client’s ‘first disclosure’ as such, if it was made to you. You’d be doing your client a disservice if they later wished to pursue a legal course and your notes couldn’t corroborate their disclosure sequence. Validate a survivor’s experience of their abuse Validation of a survivor’s experience is an important aspect of disclosure work. It may be regarded as occurring at two levels. At a macro level it repudiates a survivor’s self-blame. As noted previously, survivors often grow up blaming themselves for their abuse. It is important for you to constantly counter this in early sessions each time it becomes apparent. That a child cannot be held to blame for abuse perpetrated by an adult is an important statement for you to make, and one that might need to be repeated. Convey it as a considered statement rather than as a quick judgement, particularly to an ambivalent survivor who might still care for the perpetrator despite the abuse. At a micro level, your validation allows a survivor to also identify their current inappropriate attitude of self-blame and guilt in everyday situations. This is an essential aspect of abuse-specific work. It allows them to see how past abuse continues to affect their current interaction. A survivor needs to be aware of these interactions in an ongoing way to address complex issues. Help a survivor to get in touch with painful emotions Survivors may use their early sessions with you to express or talk about their painful emotions. They may do this elsewhere as well, with people close to them. However,


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your empathetic objectivity provides a space that is different qualitatively, as well as quantitatively, from that with a friend however well intentioned. The aim in expressing painful emotions is eventually to allow the survivor to explore ways to contain them better. This in turn allows them to move on from their previously paralysing emotions. However, not all survivors are able to express such emotions to start with. A survivor whose abuse-experience was not believed in childhood might continue to doubt their adult views and experiences. For such a person current experiences, because they are more easily accessible, allow easier scrutiny to begin with. You will need to help your client to identify emotions associated with their current experiences. A tentative verbalisation by them will need to be facilitated for clarity and then validated. The process is a liberating one for them. You will find that they will then use it as a template to re-examine emotions related to past experiences. ‘Tanya’ was unable to account for her increasing depression of the past few weeks in terms of any recent life events. She regarded the worsening to be related to her childhood abuse in a general way, but had no explanation as to why it should produce the current worsening. Later in the session she mentioned in passing that a tradesman was expected to carry out some repairs at home. It then emerged that her partner had put his fist though a wall some weeks ago. Tanya had not considered the event relevant to mention, as she’d not at any time felt in personal danger from him. Even when asked about the incident, she described her partner’s intense neediness alternating with remorse, his abusive and violent childhood, and his current need for help. There was no mention of her own emotions during the incident, which to my view seemed to coincide with her worsened depression. Tanya found such exploration, at my instigation, difficult. But I persisted as I felt it would be important for Tanya to identify her immediate emotional response to the incident. It was only by getting Tanya to visualise the fist going through the wall, and focus solely on it, that we were able to keep other issues from intruding. The technique allowed Tanya to identify the fear she had experienced at that time. It was an intense fear and one that was palpable even in our session, some weeks after the incident. Our process allowed Tanya to realise that she had glossed over her fear in the face of her partner’s more overt desperation. Identifying her fear during the incident was a relieving experience for Tanya. It helped to lift her current depression, but it also brought to Tanya’s mind a similar childhood fear during her father’s ‘drunken rages’. Working with complex emotions, and the flow-on from disclosure work into memory work are discussed in Chapters 8 and 9.


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Content of early work n n n

Disclosure work Survivor’s experience of abuse Painful emotions

Strategies in early abuse-specific work A central feature of early abuse-specific work is to help a survivor to understand current symptoms and their relevance, if any, to past abuse.

Reflecting on old times can stir up a lot of emotions, as we know. Even if your client is not talking specifically about their abuse, she/he is probably focussed on a period of childhood that they might have sidelined for years as part of a survival strategy. Now the subject of deliberate scrutiny, it could generate old emotions and helplessness. A central feature of early abuse-specific work is to help a survivor to understand current symptoms and their relevance, if any, to past abuse.

Provide information Your client’s current symptoms may not be in the realm of emotions at all. Symptoms might take the form of strange bodily sensations, or confusing behaviour. A client who might have been prepared to feel sad or angry during the process with you, mightn’t recognise their current heightened sense of helplessness, or urge to bingeeat, or the ‘heaps of time just going around in a haze’. You, the practitioner, are in a better position to identify these phenomena among several other casually mentioned topics. You also have information from their assessment sessions as to how the client has reacted to stress in the past. You are now able to offer your observation. Naming these phenomena will come as a relief to your client. Your client may not realise that their frequent floaty feeling could be a sign of anxiety, for instance. Anxiety, as we know, can manifest in unusual ways— perceptual distortions such as objects appearing to shrink, or loom; near sounds seeming distant, or ordinary ones, overly loud. You are better placed to recognise these as part of anxiety. Another client might only note their current meaninglessness in life. If they do not experience the specific emotion of sadness, the person might not think to name their situation as depression related. They may not have registered their gradual loss of motivation. Providing such information is an important part of early abuse-specific work.

Help the survivor to understand their symptoms You are now in a position to guide the next step of exploring a link between your client’s symptoms and the abuse material they’ve started to speak about.


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Early sessions are ideal for discussion of specific phenomena described by the survivor. To know that a symptom is caused by anxiety or depression—once you establish that this is indeed what is happening—can be reassuring. Naming an emotion or a situation for what it is helps the survivor. If you are unsure as to the nature of your client’s symptoms, request assistance from the local GP, or mental health team. Once you have established the nature of the symptoms, you and your client are able to work on suitable techniques to address them. Establishing the nature of your client’s experiences increases their confidence in their own ability to contain distress. This, in turn, allows them to feel less helpless and more in control. ‘Vicky’s’ phenomenon of altered body sense, became apparent in an incident involving a work colleague. ‘It was scary,’ said Vicky, ‘the way I looked when I came to’. ‘What do you mean?’ I asked, ‘the way you looked—could you see yourself?’ ‘The way I think I looked. I looked like my grandfather.’ ‘What was scary?’ I asked. Vicky thought a while before responding. ‘It was as though my head was sitting on my right shoulder,’ she said finally. ‘It was ghoulish this time, evil.’ I began to make sense of the drift. She referred to this time, as though there’d been a different type of experience another time. ‘Had you ever experienced this before, Vicky?’ I asked. ‘Not on my right shoulder,’ Vicky replied. ‘Generally, when I lose it, my head sits on my left shoulder.’ I knew the it she referred to was the ‘losing time’ she had mentioned previously. I decided to verbalise the sense I was getting. ‘I think I am beginning to get the sense of it,’ I said. ‘Let me have a go at putting something into words, and if you think it is along the right lines, we can take it further. This period of time that you describe as lost, could you have been experiencing some intense emotion?’ Vicky considered this carefully. Her eventual response was not a direct answer to my question but someone’s description of her when she’d gone into ‘a rage’ once. She had retained only a vague memory of it herself—except for a sense of her head sitting on her left shoulder. I took her reply to indicate that she was agreeing with my hypothesis. So I suggested that in addition to losing time, she might also be experiencing an altered body-sense: one of her head sitting on a shoulder—that, perhaps, it seemed to sit on her right shoulder with a certain type of intense emotion, and on her left shoulder with another kind of emotion. The ‘coming to’ herself after a period of time indicated that her normal body-sense was resumed after a period of alteration.


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Vicky’s response pertained to her grandfather. He had, she said, seemed a totally different person during his acts of abuse: ‘evil’, ‘ghoulish’.

Discuss social aspects Awareness of historical and societal aspects could be immensely helpful to your client in initial stages of this work. Many survivors draw some comfort from an acknowledgement of the extent of society’s denial of abuse issues. The denial they encountered, for instance, to a childhood disclosure gains a broader social context for them in addition to the family one. ‘Jenny’, in one of her early sessions, described being taken by her stepfather to a doctor for the contraceptive pill. This was in the 1970s; she was a teenager at the time. ‘Why did these doctors never suspect something was wrong?’ she asked. Jenny was referring to her stepfather sitting in during the consultation. Jenny had only recently become critical of the doctor’s unquestioning acceptance of the stepfather’s presence. At the time, she had interpreted it as confirming her belief that she had no rights because, somehow, she was to blame for the situation. I acknowledged the immensity of the issue and the inexcusable lack of vigilance on her behalf, by the doctor. I also reiterated that a child is never to blame for the adult’s behaviour—that she was not to blame for the abuse. I then made a tentative comment that few practitioners at the time would have considered sexual abuse to be relevant in their own clinical practice. I stated that it did not excuse the professional, but wondered whether a perspective on the times would be …it is also possible of any relevance or interest to Jenny. It turned out that it was. Jenny was interested to hear of societal aspects—the that your client might active lobbying that had been needed in the past three know more than you decades to increase professional awareness of childhood do about societal sexual abuse. aspects of this issue. Jenny said our conversation had relevance to her long experience of isolation and guilt. For groups to take on this issue and fight for its awareness in society meant, to Jenny, that there would have been thousands like her. This, in turn, helped counter some of her ‘I’m to blame for the situation’ thoughts. Such information and discussion may need to be repeated throughout the process of abuse-specific work—not only because high anxiety levels impair a person’s capacity to process them, but also because feelings of guilt and self-blame are often ingrained and habitual. In reverse, it is also possible that your client might know more than you do about societal aspects of this issue. This is not a matter to get nervous about. After all, many


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survivor groups have been considering the topic of childhood sexual abuse for longer than some professional groups. You and your client are a team in this collaborative approach. Openness to hearing your client’s understandings regarding abuse-related issues is an important facet of the work. Between the two of you, there’s likely to be a fair amount of information. What the survivor provides is their personal experiences as well as their understanding of how these fit within the societal context. You bring your openness to hearing these, your professional training—as a social worker, nurse etc.—that has taught you to observe in a certain way; and your database of knowledge. Pooled, these will be immensely helpful to a survivor exploring links between their current issues and past abuse.

Give practical help to develop coping strategies The best coping strategies are those grounded in the existing life skills of a person. As no two people are identical, determining your client’s range of existing skills might require your sessions to cover minute details of their current life events and/ or symptoms. No detail is too mundane or irrelevant for the purpose of developing coping strategies tailored to the individual. ‘Nina’ felt suicidal following an access visit from her child. We had already established that access visits, for Nina, often brought up memories from her own childhood. Nina had come to me for help with her depression. Her life story involved childhood sexual and physical abuse from her father, as well as re-abuse and victimisation in later life. She had worked with an escort agency while in her 20s—a period of living in hotels or plush apartments, dressing expensively, and posh dining in restaurants or on take-aways. Her lifestyle changed significantly when she entered the relationship with her child’s father. She gave up escort work for a series of casual jobs that ended when she became pregnant. Although the pregnancy had been unplanned, she decided against a termination. She was dedicated to her infant daughter, managing with no help besides her partner. But the relationship ended. Convinced that she would not make a good mother, Nina agreed for her two-year-old daughter to live with the father. This started a period of deep depression that led to Nina seeking me out. This session in question came soon after assessment. We first explored her level of suicidal risk: the nature of her thoughts; their intensity and frequency, and whether she had anything like a suicidal plan. We then explored her coping strategies for use before her child’s visits as well as after. No detail was unimportant. Topics we covered included Nina’s food habits and daily routines, among others. It emerged that Nina had little knowledge


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of balanced diets and felt very insecure about her lack of practical cooking and budgeting skills. We even spoke of what fillings she put into sandwiches, and where she shopped, given her budget. This extent of detail would have been incongruous with someone who managed this life function adequately, but not with Nina. She could not remember ever watching someone make a sandwich for her in childhood. Nina became tearful at my comment that role modelling was generally how children learnt such skills and that it stood to reason that she would not be confident about her ability to mother, or run a household, as she had never experienced consistent role modelling herself. The session also brought the information that Nina experienced occasional peaceful moments tending a small garden plot. She particularly enjoyed digging hard soil, and the process of turning it into a rich garden bed. In this, we had hit upon a technique that she could use in future to contain some of her distress and anxiety.

Maintaining a balance Striking a balance in sessions between emerging abuse issues and a survivor’s practice of coping techniques is vital. While this is true of all stages of abuse-specific work, some additional issues face Striking a balance you in early stages. These are related to the newness of in sessions between the interaction between you and your client. Your client’s emerging abuse painful emotions are at this stage emerging into a relatively issues and a survivor’s unfamiliar interactive space. In addition, you and the client practice of coping are still in the process of devising new and appropriate techniques is vital. coping strategies for them to use. Some guidelines could assist you with achieving a balance between containment and exploration: • Allow your client to guide the pace of work. This allows the process to tap into the survivor’s instincts for coping. • If your client’s coping appears to founder, slow down disclosure aspects of the work. This gives them time to become proficient with their new coping techniques. Remember, for your client to experience helplessness, this time in the therapy process, can be quite overwhelming, and is something to be avoided.

Maintaining safety in early work As discussed in Chapter 3, maintaining a client’s safety is an intrinsic component of all stages of abuse-specific work. In the early stages of this work this issue requires you to take the initiative. Later in the process, as the survivor becomes more knowledgeable and adept at monitoring themselves, it is more of a shared role. Awareness of coping levels and the need to match coping strategies to the type of risk were discussed in Chapter 4. Now is the time to put safety protocols into place.


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Difficult topics emerging in early sessions and the emotions associated with them should not leave the survivor with raw, open feelings after the session has ended. There are many anecdotes from survivors, of wandering the streets in a daze— putting themselves at physical risk—following an outpouring of emotion in disclosure work. The words, ‘I’ve not gone to such a depth with anyone’, from your client at the end of a session should be taken as a prompt to debrief. This is the time to check that your client: • is aware of the intensity of their emotions as they leave your session • is aware that they must continue to be mindful of intense emotions after they leave • has strategies to handle the emotion after they leave. In an especially heavy session, I use precious final minutes to check. ‘It’s been heavy going’, I might say. ‘Do you think you’ll be all right later?’ or ‘Perhaps we should stop talking about these heavy issues and take a few minutes to check how you might cope after leaving here’. It is useful for your client to expect to feel tired and drained following a session with much expressed emotion. If this doesn’t eventuate, then that’s a bonus. They should, in such a situation, also be mindful of their emotional state for the rest of the day. It is a good idea for a survivor to debrief themselves routinely after each session— even if the session has not been particularly heavy. Simple debriefing measures like a walk in a nearby park before resuming daily routines could make a significant difference to long-term benefits of the process. It also encourages your client to use more specific anxiety-reducing techniques, if needed. ‘Sonya’ had a set of strategies for use after difficult sessions. She’d go for a brisk walk in the evening and also drag herself, despite considerable inconvenience, to the swimming pool the next morning. Sonya had started this routine before our sessions got heavy. Our early discussion of possible increased distress as well as what strategies she might use led her to a ‘might as well start now’ response. Of course, when the need arose she was particularly glad the routines were already in place. Motivation such as Sonya’s, to develop new coping techniques and her impressive determination and self-discipline are not uncommon. And finally, if your safety check reveals risk, discuss this with your client in the first instance. She/he might be able to recruit help from their own support network. If not, you will need to come up with suggestions. Stay within your practice guidelines. Principles for managing risk and safety were discussed in Chapter 4.


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Early strategies n n n n n n

Help the survivor to understand their symptoms in the context of their life story. Provide information. Discuss societal aspects. Develop coping strategies. Maintain balance between emerging abuse issues and capacity to cope. Monitor safety.

Techniques in early abuse-specific work Let us now consider how you might translate the above principles and strategies into techniques. This might come as a surprise, but you will actually be on familiar territory here. The techniques you will use are Abuse-specific work those you’ve already acquired in the course of your training, does not require and have polished and refined over the years. The skills you you to practise new will use in abuse-specific work are the very ones you use techniques, only to with your other clients. It’s the principles and aims of abuse incorporate abusework that are specific. specific principles and If, for instance, your preferred mode is in a cognitivestrategies into your behavioural range, then that is what you will continue to use in abuse-specific work. If your skills are psychodynamic, existing techniques. or a combination, that’s what you will use. Abuse-specific work does not require you to practise new techniques, only to incorporate abuse-specific principles and strategies into your existing techniques. This dictum becomes particularly relevant in maintaining a survivor’s safety. With your knowledge of your own skill base, you will know precisely when to get additional help. Managing risk, as we know, is as much about not overstepping the ‘duty of care’ guidelines of your training and work practice, as it is about identifying client risk. The following section will examine some examples drawn from my own repertoire. They are based on cognitive-behavioural and psychodynamic techniques as well as pragmatic considerations. I have selected two from previously mentioned abuse-specific principles and strategies to discuss at greater length with regards to techniques: • Survivor control over the process of work • Facilitate survivor coping. The discussion will aim to illustrate how principles and strategies of abuse-specific work may be translated into techniques irrespective of the training background of the practitioner. The techniques you use with your client will come from your skill set.


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The discussion will also illustrate that principles of abuse-specific work form a cohesive spectrum. For instance, the more a survivor controls their process of work, the more initiative they are likely to take in devising coping strategies. A successful coping strategy enables your client to feel more in control and the less at risk from self-harm. The occasions when your client will need to access these abilities is, obviously, going to be mostly in their own time—outside session time with you. So although you might initially provide your client with some techniques from your skill repertoire, it helps your client immensely to be able, eventually, to devise or adapt techniques to suit specific situations as they arise.

Techniques to facilitate survivor control over the process Techniques for this might be verbal as well as non-verbal—in behaviour or in the attitude a practitioner conveys. Verbally you might, for instance, make fewer ‘expert’-sounding statements. In your behaviour, you might, perhaps refrain from coming up with ‘solutions’ yourself, instead facilitating your client to take the initiative. Remember, your particular techniques in this regard are to be drawn from your usual mode of practice. Maintaining a constant and conscious awareness of abusespecific aims allows you to adapt your techniques appropriately.

Techniques to facilitate survivor coping Chapter 4 discussed the general principles for managing risk in abuse-specific work. These were to gauge a survivor’s level of coping, to facilitate coping strategies, and to devise safety protocols. We also discussed, at some length, how to gauge your client’s level of coping. We will now explore techniques to enhance a survivor’s coping with regard to: • what might suit them, and • your expertise and training background. First and foremost, your client needs to feel she/he can contain, or stay on top of their distress. Obviously this will depend on the intensity of the distress at a certain time. Chapter 4 gave you a way to grade this. The term ‘distress’, however, is an all-encompassing one. It could be a mix of sadness, anger, anxiety, or depression—their proportions varying over time. In order to devise coping strategies, you and your client will need to identify the nature of their current distress. Is it mainly sadness, anger, anxiety or depression at a particular time? Each of these will benefit from rather different techniques. Anxiety-reducing techniques differ from those to alleviate depression. Further, specific goals with regard to each will need techniques to be accordingly finetuned. For instance, techniques to contain anger differ from techniques to express anger in constructive ways.


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Your client might find it easier to differentiate sadness from anger, but differentiating anxiety from depression may not prove as simple. The latter two are, unfortunately, often intertwined in the term ‘stressed out’ of lay usage. People tend to describe themselves as being anxious/depressed as though these were interchangeable terms. However, because techniques to deal with anxiety differ from techniques that benefit depression, you will need to help your client to differentiate between them. Without going into complexities at this stage, anxiety is often a churned-up emotion, while depression tends generally to be a flattened emotional state. Of course, there are exceptions. A more detailed account of types of anxiety and depression appears in Chapter 7. Once components of ‘distress’ are identified, you and your client can go about developing appropriate techniques to contain them. Anxiety of crisis proportions might need the use of a combination of methods. Even if people take recourse in medication at such a point, it would be advisable that they also acquire alternative medium and long-term techniques. Cognitivebehavioural methods are useful to this end.

Anxiety-reducing techniques Anxiety-reducing techniques aim to foster a ‘still’ mind. Behaviour techniques aiming to reduce anxiety have three components: • mind focus • breath • kinaesthetic/muscular. Numerous combinations are available these days in the form of stress management or relaxation therapies. A browse through the Yellow Pages or their local paper will give your client a range of ‘brand’ options within complementary medicine, yoga and martial arts. Your client would be well advised to try out a few different types before signing up for a whole course. Each ‘brand’ is likely to address the above-mentioned basic components in its own way. For instance, one method could use a visualising technique as its mind focus component, while another uses the repetition of a set of words. As regards the muscular component, one method might involve vigorous movement, while another requires the client to sit or hold a certain posture. As anxiety generally leads to shallow, rapid breathing, most anxiety-reducing methods advocate that a person gradually slow their rate of breathing, eventually aiming to equalise the duration of their in-breath and out-breath. I find it useful to group anxiety-reducing techniques into two broad categories: those that are stillness based; and those that are movement based. A client with an unduly high anxiety level is better off starting with a movementbased method, particularly if they are a newcomer to such methods. It is not unknown for a stillness-based method like meditation to sometimes precipitate a panic episode in a state of high anxiety. Once the anxiety level has reduced somewhat, your client could move on to a meditation technique, if that’s what they are attracted to.


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Depression-related techniques Undoubtedly, use of anxiety-reducing techniques will in the long run help your client with depression too. However, for more immediate help with depression other techniques will be needed. As noted earlier, depression tends, in the main, to produce a flattened state of mind. If the essence of an anxiety-reducing technique is to foster a ‘still’ mind, the essence of a technique to address depression is to help ‘lift’ it. Such a technique does not, however, raise the mood state of a person to one that is above their normal level, as is the case with the use of ‘designer’ drugs. Techniques that effectively tackle a survivor’s depression in abuse-specific work could be a combination of the following: • cognitive-behavioural • psychodynamic • medication. Bear in mind that you can only help your client from your skill base. The techniques you and your client decide on will need to fit your own skill base. They may not be identical with the examples of depression-related techniques appearing below, that are based on my repertoire. Alternatively, you may decide that your client will need to seek depressionrelated techniques from another practitioner. If so, all three—you, your client and the other practitioner—need to be clear as to each person’s role. Cognitive-behavioural techniques used for depression often tend to be individually tailored, and based on past ‘comfort’ benefit to the person. Other techniques involve exercise and movement. Athletes and others who exercise regularly would know the lifting effect of endorphin release. Another cognitive-behavioural technique—the ‘stop’ technique—could be useful for repetitive negative thoughts. This said, universal techniques such as those for alleviating anxiety seem less available specifically for depression. You and your client will first need to identify the strategies and behaviours that have helped to lift their depression in the past. This provides a starting point for modifications to suit their present circumstances. Psychodynamic techniques are invaluable, used in conjunction with the behavioural techniques your client has decided to use. Identifying life events that trigger your client’s current depression are of immense help. Often, a survivor does not recognise the correlation between a certain life event and their current depression. This is where you can assist. Even if you’ve designated medication or cognitivebehavioural techniques to another practitioner, the survivor needs your help to explore correlation between life events and their mood state. Because of their increasing trust in you the survivor is more likely to uncover re-enactment of old patterns, and recognise the pressing of old ‘buttons’ in your sessions rather than elsewhere. Importantly, unless this aspect is handled concurrently, other ‘depression-lifting’ strategies will be only partially effective. For instance, if the survivor’s current


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triggering factor is renewed contact with their perpetrator, it is essential that some strategy to handle this be devised. Medication, too, may need to be considered for depression. A brief word about antidepressants would be useful at this point. It is possible that this has been the main, or only, option available to your client until now for their depression. It is also possible, that as you are reading this book, I’m speaking to the already converted. But it is worth repeating that in my view medication alone is seldom sufficient in abuse-specific work. While it could help with depressive symptoms, and indeed may sometimes be needed, long-term benefit for survivors requires abuse-specific work. The reverse too, needs to be stated. For certain survivors, appropriate initial intervention for their depression may be the use of medication. In such situations you might establish a useful collaboration with a GP or a mental health team, allowing you to continue abuse-specific work with your client while the other practitioner assists with your client’s medication.

Worker-related issues in early abuse-specific work Awareness of possible worker issues allows us to watch for them. Overall worker issues in this field, such as anxiety and avoidance, were discussed in Chapter 4. We will now consider some issues particular to early abuse-specific work. Over-identification is an issue to be mindful of in early stages of the work. Attitudes stemming from your own personal or political ideology are best avoided in your responses to client statements. The earlier mentioned example is a useful one in this regard—too vehement a condemnation of the perpetrator could be counterproductive for a survivor who still has warm or ambivalent feelings towards this person. Over-identification, which leads you to take a vigorously active and caring role with an intensely needy client, might also sustain the passivity and helplessness felt by them. Another issue to watch out for at this stage is that of taking a saviour role. For instance, ‘I can help better than others because I really understand the situation [and they don’t].’ Such a view contributes to potential splitting discussed in Chapter 5, between agencies and workers you collaborate with. Worker-related issues in early abuse-specific work n n n n

Anxiety (e.g. ‘Will I be able to handle what is uncovered?’) Avoidance (e.g. easier to focus on symptoms such as suicidality or self-harm) Over-identification Saviour role (e.g. ‘Others don’t understand.’)

More worker issues pertaining to ongoing abuse-specific work are discussed in Chapters 8 and 9.


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CHAPTER 7

Underpinnings of ongoing abuse-specific work CHAPTER AT A GLANCE Mental ill health depression anxiety dissociation post-traumatic stress disorder psychosis

Body-sense and somatic signals Mind-altering substances The matter of personality The issue of insight

Many primary health practitioners are involved these days in the care of adults who have a mental illness. Many among this client group have been sexually abused in childhood, and it is not uncommon for such survivors to approach their primary health practitioner for abuse-specific help. This chapter explores the interface between adult mental illness and childhood sexual abuse. The complex combination of issues presented here provides the basis for ongoing work with survivors, and for the further level of strategies and techniques of abuse-specific work to be described in Chapters 8 and 9. The discussion assumes that irrespective of the nature of your training—social work, nursing etc.—your duty of care with such a client is that of a primary health practitioner, not a specialist mental health worker. Let us assume you’ve been providing abuse-specific time to your client—perhaps a dozen sessions at a healthcare agency, or as a sole practitioner. You’d initially thought you would have finished by now. Your client says that your sessions are precisely what she needs. But she needs more because her depression, for instance, continues. She says that the local mental health team, also involved in her care, does not address issues related to her childhood sexual abuse. They focus on your client’s


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symptoms of depression, suicidal ideation in particular. Alternatively, the mental health team might have said that your client is too ‘well’ to warrant their involvement because of time constraints. This chapter aims to help you to understand aspects of your client’s mental illness in the light of their past sexual abuse. The treatment of such mental illness must obviously lie with the survivor’s mental health professionals. You and the client need to be clear at all times about demarcation between roles, and the respective duty of care of each of the involved workers.

Mental ill health In simple terms, mental illness is of two main types: the neuroses where we remain in touch with reality, and the psychoses where we lose touch with reality. Anxiety and depression fall within the first group; psychosis, in the second. Personality disorders and substance-use, also of relevance to survivors, lie outside these two groupings. A survivor of childhood sexual abuse, like anyone else, could suffer any type of ill health. Alternatively, they might have a mix. As appropriate help-strategies differ, it is necessary to know the nature of a survivor’s predominant symptoms.

Depression Depression is the most common mental illness experienced by survivors of childhood sexual abuse, in terms of sheer numbers. This statement derives from depression being noted by the WHO Global Burden of Disease as the most prevalent of all illness—not merely among mental illnesses—in the developed world today. The importance of depression is relevant because of the publicity given to posttraumatic stress disorder (PTSD) in connection with childhood sexual abuse. The two terms are sometimes even used interchangeably. This could be problematic for survivors because PTSD is mostly an anxiety-related disorder. A survivor with predominantly depression-based symptoms would not benefit from techniques and strategies for anxiety alone. It is also of relevance that ‘depression’ used as a clinical term has attributes besides depressed emotion. Physical aspects such as weight loss; and functional ones like disturbed sleep, appetite and libido are examples of other attributes. ‘Ivy’ began to suffer from severe depression when aged in her early 40s. She was treated with various medications, as well as shock treatments, without benefit. Her attempt, early in her treatment process, to speak of her incest was not ‘heard’. She was unable to raise it again until her 60s. ‘Sarah,’ aged in her early 30s, was constantly tearful and depressed following the birth of her first child. She lacked energy to care for the baby. Sarah’s loss of appetite quickly led to weight loss. Her depression was triggered by flashbacks of childhood abuse.


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The two case examples demonstrate the wide variety of depression that survivors might experience. Ivy illustrates the longstanding course depression can take. Sarah’s post-natal depression, triggered by flashbacks, illustrates that survivors often have a mix of symptoms.

Anxiety Anxiety is another common problem experienced by survivors of childhood abuse. In ordinary usage, the term refers to a feeling of apprehension. Anxiety as a symptom generally begins at a younger age than does depression. Also, people experiencing anxiety tend to seek help earlier than those who have depression because of the energy-turbulent characteristics of the symptom. The clinical syndrome of anxiety includes physical symptoms like shortness of breath, palpitations, increased sweating, or nausea. Sometimes these physical aspects overshadow emotional aspects. For instance, a survivor may seek help for persistent nausea or diarrhoea without recognising it as part of a ‘state-anxiety’. Anxiety as an illness-disorder could occur either as a pervasive, generalised state; or in episodes that may reach panic proportions. Panic is a sudden episode of severe anxiety. A survivor’s panic may be triggered by an obvious life event, or by an internal trigger that goes unrecognised by them. Not uncommonly, people describe their first panic attack as having woken up suddenly at night gasping for breath or with chest pain, thinking that they are having a heart attack. ‘Dianne’ was in her early 40s when she began to experience increasing anxiety. She had to leave work on several occasions because of panic episodes. Having previously handled several major life crises, Dianne found it difficult to understand these episodes, as they had no obvious triggers. Taking time off work only made matters worse. Dianne then decided that it was time to consider the childhood sexual abuse that she had always remembered, but intentionally put aside until she had the ‘time for such indulgence’. Anxiety as the main feature at the age of 40—as with Dianne—is somewhat outside the norm; depression would usually be the pressing concern in her age group. Anxiety and panic are generally more common among younger people.

Dissociation ‘Dissociation’ is a term that is used increasingly these days. However, as noted in Chapters 3 and 4 it is perhaps the most difficult of experiences to describe accurately. Each person seems to use the term with a different meaning. For one person, dissociation signifies a certain type of feeling, for another, it could signify a certain behaviour. Dissociation is often recognised only in retrospect and, even then, merely as ‘an absence of something’ for a while. This could be an absence of awareness of external events, or the absence—or alteration—of a bodily sense over a period of time.


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A psychiatric definition of Dissociative Disorder describes its essential feature to be a ‘disruption of the usually integrated functions of consciousness, memory, identity, or perception of the environment’. This complex definition reflects, perhaps, the nature of the illness. Types of the disorder include dissociative amnesia, fugue states, identity disorder and depersonalisation. Dissociative phenomena could involve emotions, complex behaviours, or, more rarely, assumption of distinct personalities (Dissociative Identity Disorder). Adding to the confusion is that the term ‘dissociation’ is also used for a type of ‘defence mechanism’ of the mind. As we know, defence mechanisms—of which denial and projection may be better-known examples—are subconscious psychological mechanisms that protect the conscious mind from something unbearable or unacceptable. People experiencing the phenomenon of dissociation might describe ‘losing’ a chunk of time. For example, ‘I remember I was…[doing something], the next thing I remember is...[doing something else], but I can’t remember anything in between, even though I’ve tried hard to.’ Or, they might say something along the lines of, ‘I know I was at…[a place] then, suddenly, I’m at…[another place] and I just don’t know how I got there.’ In neither of these two instances is the person describing a loss of consciousness. They continued to function during the period in question in an apparently normal manner. What is missing here is the memory pertaining to a finite period of time and this is recognised only in retrospect. So, why might such a person not have been merely preoccupied or daydreaming? Because a person, who is preoccupied, or daydreaming does not totally lose touch with present time. Such a person remains aware—if only vaguely—of their surroundings, even though their mind is absorbed with their preoccupation. In dissociative states, by contrast, when the person regains their normal stream of consciousness, they are mostly unable to access events of the previous period. As a consequence, they are distressed and unsettled because they are aware that something out of the ordinary has occurred. An altered body-sense is another type of dissociation. ‘Out of body experience’ is a term often encountered these days. Survivors in a ‘triggered’ situation often describe perceiving themselves in a ‘second self’ that functions in parallel with their normal self: ‘I was on the bed, but also up on the ceiling watching myself on the bed,’ or, ‘I was there and yet not there’. Although dissociation might provide some distancing, or relief from the event that is triggering it, it can be intensely distressing in itself. A feeling of ‘about to disappear altogether’, for instance, can generate immense fear and anxiety. Some survivors are able to describe their experience, while others may need questions to be put to them. ‘Nadia’ described an episode of losing time that had occurred soon after she spoke about her abuse for the first time to a counsellor: ‘I thought I was losing my mind. I kept losing time’, she said. ‘I lost three


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days. I still don’t know what I did in those three days. My friends didn’t know where I was.’ Unfortunately, because the term is ill-understood, it may be used inaccurately by survivors as well as workers. ‘It is dissociation that I find difficult to handle’, said a health practitioner in a workshop. ‘I feel I have skills to work with post-traumatic stress, but not with dissociation.’ But her more detailed description of the specific behaviour showed that she was referring to repeated suicidal attempts rather than dissociation per se. A person may carry out complex behaviours like self-harm or suicide attempts during a dissociated state, but the terms are not interchangeable. A dissociative state needs to be properly established in addition to the behaviours enacted during it.

Post-traumatic stress disorder (PTSD) Post-traumatic stress disorder is a diagnostic category used for a group of symptoms that occur against a background of trauma. It comprises distressing memory-experiences, in the form of flashbacks, along with symptoms of anxiety or depression. Historically, this diagnostic category was initially created to accommodate and legitimise the range of symptoms experienced by Vietnam war veterans in North America. With the emergence of abuse trauma into the current health scene, clinicians as well as survivors often inaccurately assume that a PTSD diagnosis is the most appropriate one for a survivor. It should only be used if the diagnostic criteria for it are met.

Psychosis In the simplest of terms, psychosis is a break with reality. The two main types of relevance to this discussion are Bipolar Affective Disorder and schizophrenia. Each of these illnesses has several features that might require specialist mental health intervention in the first instance. In the longer term, however, survivors with either illness might seek abuse-specific help from primary healthcare practitioners. In such a situation, it is likely that a practitioner, whether a solo worker or at a healthcare agency, will find themselves collaborating with a mental health team in the long-term healthcare of the survivor. This section discusses some preliminary considerations with regard to psychoses that have a bearing on the ongoing abusespecific work to be described in Chapter 8. Survivors with an affective disorder require appropriate interventions for their mood state as well as for their childhood abuse. The depressive component of a Bipolar Disorder is variously termed biological, endogenous or psychotic depression. This type of depression is somewhat different to the depression encountered in a neurosis. The other component of a Bipolar Disorder is hypomania, which has an elevated mood state. Delusions are an aspect of psychosis, particularly of schizophrenia, that pose a special problem for a survivor of childhood sexual abuse. Very simply, a delusion


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is false, unshakeable belief that is not in keeping with the individual’s personal and cultural background. It is a psychotic symptom and requires treatment as such. When an adult survivor makes a first disclosure of childhood sexual abuse during a psychotic episode their treating professionals face the dilemma of deciding whether the statement is factual or a false belief. Some mental health workers might find it easier to avoid grappling with such a complex issue. Conversely, others might feel they owe it to the survivor to ‘do something about the abuse’, for instance, help them to confront the family as part of the treatment process. ‘Phil’ was 25 when he came to the attention of his mental health service. He believed that he was being watched and followed; with his movements monitored by devices. He stopped work and eventually got to a point when he would not leave his room except to buy essentials at the local convenience store. In reviewing his past history, it appeared that Phil had cut his penis a year previously, requiring many sutures. Phil was prescribed anti-psychotic medication, but was reluctant to take it. He missed many appointments at the mental health clinic. It later emerged that Phil’s symptoms had commenced not long after a court case related to his sexual abuse in childhood. His mental health workers, however, did not go into the matter, as Phil mentioned he was receiving some counselling from a ‘sexual assault’ agency. Eventually, though, it became apparent that Phil was not in regular attendance at the other agency either. Despite this, the mental health team remained uneasy about exploring abuse aspects for fear that they might worsen his illness. It is also not uncommon for a survivor to speak about their abuse during a psychosis but not when they are better. The person’s mental health team might assume that this indicates that the talk of abuse was part of the survivor’s illness, instead of checking it out with the survivor during remission. ‘Louise’, aged 41, had her first psychotic episode at the age of 27, with seven further admissions to psychiatric hospitals. Lately, she was able to recognise early signs, and seek help; thereby averting a prolonged psychotic episode. One of these early indicators was a preoccupation with ‘good and bad sides’ to her that she believed were controlled by God and Satan. In a recent episode, Louise had contacted her local mental health clinic with signs of recurrence. This time, however, she also spoke of being sexually abused in childhood. Her clinical team disagreed over its relevance. One of the workers however allowed Louise time to speak about it. Through the next few weeks of clinic and home visits, Louise’s psychotic symptoms continued to fluctuate.


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Then, through a combination of routine rostering and illness, the said worker became unavailable for a period. Other team members, although continuing to check on Louise’s day-to-day requirements and medication, felt less competent regarding the issue of childhood abuse. Concerned that they might worsen her condition with a wrong response they initiated a referral to a ‘sexual assault’ agency. That agency was reluctant to take on someone as obviously in need of mental health expertise as Louise was at the time. Nevertheless, they agreed to see her. Louise—voicing neither reluctance nor enthusiasm—merely deferred to the judgement of her team. She did, however, request that a mental health worker accompany her to the new agency, if possible. Before the referral eventuated, Louise’s condition deteriorated rapidly and she was hospitalised once more. Whether or not the abuser had indeed performed the acts Louise described became a major issue for her hospital workers. Would the family have to be confronted during the admission? A ‘truth or delusion’ debate ensued. Some feared that dwelling on her abuse during an active illness could worsen it. Others felt they didn’t know how to handle issues that might come up. Concurrence could not be reached between workers. A review of her medical records showed that Louise had raised the abuse issue as early as her first admission and continued to do so in some further admissions. It was unclear whether she had continued to speak about it when her psychosis was in remission. In other situations, the acts of abuse described by some persons with a psychosis might sound too bizarre to be true. The response of their workers—belief, or otherwise—could be a pivotal one for a survivor who has, indeed, experienced these acts. If these incredibly terrible experiences have contributed to the psychosis, should the fact not influence their treatment? On the other hand, if they have not, the situation would be very damaging for the person said to have committed the acts. There are no easy answers in many such situations. ‘Karen’, who was 21, had been given several diagnostic labels over the previous five years. Her first psychotic episode had occurred just before she turned 16. In a routine family session with her parents, who had separated a few years previously, Karen’s mother accused the father of incest. He denied it vigorously. Formal investigations were instituted as a consequence, but later dropped. Karen continued to have psychotic and suicidal periods requiring ongoing input from mental health services. During psychotic periods she spoke of bizarre sexual acts perpetrated upon her, without actually naming the perpetrator. When not in a psychotic state, she refused to speak about the acts saying they were her ‘private business’. Her life remained chaotic and disorganised; Karen seemed on the verge of psychosis throughout the next five years.


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Some of her mental health workers regarded her statements as delusions— and a symptom of her psychotic illness—while others were concerned that they could be factual. Occasionally, when she was very disturbed, her father, who had remarried, took her away on weekends alone. Her mother became very distressed at such times claiming an incestuous relationship between father and daughter. Karen invariably returned from these weekends more emotionally settled. Her workers were divided as to why. Was her improvement the influence of a healthy emotional security with her father, or because of an unhealthy but familiar abusive security? No one knew. None of her workers, however, disputed the seriousness of Karen’s illness. The above examples illustrate that some situations can be very complex and incredibly fraught. You might not, in your practice, need to work with a survivor in so complex a situation. On the other hand, it is possible that a survivor with a mental illness has had any discussion of their abuse issues deferred until the psychosis has remitted—in other words, until they are in your care. If such is the case, what do you need to keep in mind about delusions in the context of abuse-specific work? In essence, your approach with regard to abuse issues during a person’s remission from their psychosis will be no If you are in abusedifferent to your approach with any another survivor. It is specific work with the management of their psychosis component that will be a survivor who extra in such situations; and presumably this is already in has psychosis, the place with the mental health team. Undoubtedly, it would undertaking will need have been easier for the survivor if the mental health team to be a collaborative had taken on their abuse issues as well. But as discussed effort between you earlier, this might not be possible. and the mental So what is your role? health team. First and foremost, make sure that your client’s treatment for their psychosis is ongoing. If unclear, check it out. If you are in abuse-specific work with a survivor who has psychosis, the undertaking will need to be a collaborative effort between you and the mental health team. Get your client’s permission to have relevant discussions so that everyone is clear as to who is doing what. Or, even better, hold periodic joint meetings that include the survivor. This arrangement allows you to continue with such a survivor as you would with your other survivor-clients. In such a situation, when a survivor speaks to you about their childhood abuse, you do not need to immediately rush into establishing whether the abuse-related statement is reality based or a psychotic delusion. A health worker’s response to their client’s statement about abuse need not differ from their response to statements about other forms of perceived harm. Let us discuss this, using Phil’s example from earlier in this chapter. If, even


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during the acute stage of his psychosis, Phil had said to his mental health worker that he was being followed and his movements monitored, his worker would not have responded with, ‘That is true’, or, ‘That is not true’. Neither would they have said, ‘We will need to confront your persecutor’. They might ask questions like, ‘What makes you think so?’ They would listen carefully and consider Phil’s viewpoint. Hypothetically, if Phil replied, ‘People whisper about me,’ or, ‘They stop their conversation when I approach,’ the mental health worker would not, even then, proceed to making a true/not true judgement. They would allow more time for Phil to speak about it. Eventually, even if the worker considered Phil’s fear to be delusory, they would empathise with the intensity of his fear. They might respond with, ‘That would be very scary’, rather than look for a way to avoid discussing his experience. If Phil challenged the worker with, ‘You don’t believe me do you?’ they might respond, ‘I think you believe it, and that would be extremely distressing’. In summary, this example aims to demonstrate that survivors of childhood sexual abuse have a personal right to explore the health context of their abuse with their healthcare workers. They need their health workers to hear them out and validate their experience of it. Unfortunately, for many health workers, the issue of allowing their client to speak about abuse issues is entangled with issues related to dealing with the perpetrator. The latter aspect, they are aware, has considerations that are societal and legal in nature. The issue of confronting a perpetrator from childhood If the survivor decides is a matter for the survivor, generally when they are past to go down such a the psychosis. If the survivor decides to go down such a path, they will need path, they will need to be made aware of the societal and to be made aware of legal considerations they will face. the societal and legal Chapter 2 discussed frameworks of different service considerations they systems. Societal norms and laws are there to safeguard the will face. rights of all people in a community. The framework of the justice system requires evidence and proof, and accused persons have the right to defend themselves vigorously. Unfortunately, for a survivor with a psychotic illness, the believability of their persecutory statements—in this case, of childhood abuse—might incur additional difficulty in the light of their psychosis. The survivor taking a justice-seeking path would benefit from additional assistance from agencies with special expertise in these aspects. Some of these issues are discussed further in Chapter 9.

Body-sense and somatic signals The mind–body axis of a person is an important consideration in ongoing abusespecific work. A survivor’s awareness of links between their emotions and body may not be sophisticated to begin with. However, the holistic segment of the initial assessment described in Chapter 3 gave you emotional as well as physical aspects of


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your client’s health. As you continued sessions, you would have developed a clearer awareness of not only your client’s health problems, but also how their emotions and physical aspects interconnect in their response to everyday situations. This is a good start. These are invaluable tools for use in ongoing abuse-specific work.

Body-sense People differ in the extent of their awareness of body sensations such as bodily discomfort or pain. In addition, someone who is poorly aware of pain is also unlikely to be aware that such is the case. ‘Bronwyn’ described an incident related to a surgical procedure on her foot, under local anaesthesia. Although a double dose of local anaesthetic hadn’t quite numbed the area, Bronwyn gave the go-ahead to the surgical team telling herself a degree of pain was inevitable. As the surgeon cut into her foot Bronwyn began an old coping method. She visualised her pain as little, iridescent blue balls shooting out of her foot and away from her body. Bronwyn concentrated on her technique, but not very successfully as surgery continued. Her pain increased. Some time later, the nurse who was assisting came round to the head end of the procedure table to check how Bronwyn was going. With sweat pouring down her face, Bronwyn said she had ‘a bit of pain’. The surgical team realised the anaesthetic hadn’t worked. The nurse fainted. It was only the nurse’s dramatic reaction that prompted Bronwyn to consider that her own tolerance to pain could be out of the ordinary. Bronwyn’s disregard of her pain was not dissimilar to how she handled many other aspects of her life. Learning to acknowledge her pain experience with here-and-now specificity was an ongoing part of her abuse-specific work. People such as Bronwyn might not consciously intend to be dismissive of their pain. They are unaware of doing so. Aspects other than a survivor’s ‘threshold’ of awareness to their bodily sensations are also relevant to this aspect of ongoing work. Survivors may be consciously dismissive of their body-sense. Such an attitude stops the person from validating their experience, and from dealing appropriately with situations. ‘Sandra’ had experienced much pain in her joints and muscles over the years. She’d ‘soldiered on’, she said. ‘No point fussing. Life’s not meant to be easy.’ Her strategies? ‘Sheer hard work.’ Sandra had recently consulted a physiotherapist again for an acute worsening of ankle pain. His comment, that the condition was exacerbated by her weight, she took as meaning it was all her own fault. Sandra started to walk long distances each day, in an attempt to reduce her weight. We had previously, and periodically, discussed Sandra’s relentless pushing


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of limits and her lack of respect for her body. I commented now that, to me, she appeared to be doing this again. I suggested we try and devise a technique that would validate her experience of the pain rather than undermine it. Sandra’s reaction was a laugh. Outrageous, if not impossible, it implied. ‘I meant it’, I said. Reluctantly, Sandra put her mind to it and came up with a tentative, ‘Some stretching exercises for the joint perhaps’, based on past physiotherapy techniques. Sounded painful, I responded. Undoubtedly based on sound theoretical principles, but, to me, it did not seem respectful of her ankle. After more thought, Sandra came up with a strategy that seemed to combine respect for the pain with techniques suggested by her practitioners: if pain appeared during a walk, she would sit down to rest, perhaps on a park bench. She would then do some stretching exercises, but keeping within her pain tolerance. She might also massage the ankle, she said, but remain mindful of her pain. This was in the context that professional massage invariably exceeded her pain threshold, leaving her in considerable agony after each treatment. She had previously condoned this, holding the view that pain ‘had to get worse in order to get better’. She could also, Sandra said, ‘pamper’ her ankle with some special massage oil as part of her new validating strategy.

Somatic signals Not all our responses to a distressing situation are in the emotional realm. Who among us has not experienced that headache, or the churning tummy that we later— if not at the time—realise to be stress-induced? In these situations, we seem to bypass emotions, and respond to stress with our bodies. It is as though the trigger exceeds our coping capacity and is removed from the forefront of our awareness. It, nevertheless, continues to generate body responses and although our emotional position may be more tolerable, a problematic physical one builds. This method of coping with a traumatic event—that of body over mind—makes it more difficult for us to recognise the triggering event. Recognition is based on awareness, which in this situation was bypassed. Consequently, we can neither deal appropriately with the triggering event, nor remove ourselves from it—thereby leaving ourselves open to a further vicious cycle of more body symptoms. Chapter 1 noted that survivors could experience psychosomatic illness—where both physical and psychological aspects are significant—as part of their health aftermath. There has been research in recent years on a growing list of such conditions, and much debate on their degree of correlation with childhood abuse. Chronic pelvic pain and irritable bowel syndrome in adults, eating disorders among teenagers, and severe obesity in young people are some examples.


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The debate on the extent of correlation between these illnesses and a person’s childhood sexual abuse is beyond the scope of this book. The position adopted here is one of a holistic approach to any illness—one that gives full attention to the mind–body axis of a person. Unfortunately, the current healthcare situation is not ideal for survivors of childhood abuse with psychosomatic illness. The survivor is often unaware of the emotional component, as discussed …a survivor benefits above, and the health professional they approach for in the long term treatment of their physical symptoms may also overlook its from developing an psychological aspects. Treatment then proceeds in a biological mode. This, awareness of everyday however, is likely to provide temporary or limited benefit, emotional triggers that causing worry for the survivor, and the practitioner to run were previously being more diagnostic tests and try alternative medications. Often, bypassed in favour of it is not until such physical symptoms have been investigated bodily signals. repeatedly for biological causes—and to little avail—that survivors and their medical practitioners look for emotional triggers. By this stage, the symptoms might have become chronic and habitual in nature, and even more difficult for a survivor to overcome. Appropriate treatment for psychosomatic illness is a combination of psychological and biological methods, not one or the other method. Acknowledging psychological antecedents, such as the fact of a person’s childhood abuse, is only a first step in the work that will be needed. Psychological aspects of such work are particularly complex, and survivors are likely to need practitioners with appropriate therapeutic expertise. This book does not have the scope to include details of such specialised work. In essence, however, a survivor benefits in the long term from developing an awareness of everyday emotional triggers that were previously being bypassed in favour of bodily signals. It allows them to then deal appropriately with these triggers. ‘Cath’ had severe asthma and arthritis for which she was on much medication. Marked fluctuations in the intensity of her symptoms required constant adjustment of dosages. She also had long-term side effects from them. Fed up, Cath eventually decided to try Reiki. It was during a Reiki session that Cath remembered her childhood sexual abuse. Another couple of years passed before she sought psychotherapy. It was hard work, but Cath persisted. Slowly, she began to see a correlation between distressing emotional triggers and fluctuations in her physical symptoms. Actually recognising the triggering situations allowed Cath to do something about them, instead of merely increasing or decreasing her medications. A dramatic, sudden ‘return’ of memory such as in Cath’s example above is rare. It is more common for a survivor to have some abuse-memories, even if these have


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been pushed to the back of their mind. The point being made in the example is that for such a person with chronic psychosomatic illness, the correlation between emotional triggers and exacerbation of physical symptoms may be of considerable benefit. A primary health practitioner is clearly not undertaking specialised therapy with their clients. However, it is quite possible that you have a client you’ve been seeing for a while with regard to their childhood sexual abuse. Their GP might be treating them for irritable bowel syndrome perhaps. In other words, complex work is being undertaken in a collaborative way. In such a situation, the above discussion on body signals and triggering events would be of relevance to you. While it is important in ongoing abuse-specific work for involved practitioners to be mindful of possible psychological underpinnings of bodily symptoms, it is also important to be cautious about interpretations. For instance: • It is important not to conclude that, for a survivor, all physical symptoms are psychological in origin. It always wise, if your client develops a new physical symptom, that they check it out with their doctor. • A conclusion or ‘diagnosis’ of childhood abuse cannot and should not be arrived at merely by the fact that a certain set of physical symptoms exists—for instance, merely because a person has ‘irritable bowel’ symptoms. In summary, holistic mind–body considerations need to be promoted early when a person requests help for psychosomatic illness. Unfortunately, economic constraints in the current healthcare climate often hinder this.

Mind-altering substances Widespread use of mind-altering substances by young people is of concern to society. While there are many reasons for such use, let us consider some of these that are relevant to young adult survivors of childhood abuse. Substances could provide a survivor with a means to cope with, or escape from, their distress. The use of mind-altering substances also allows the young survivor to be part of the ‘in-set’, which counters their previous isolation and the ‘tainted’ or ‘marked’ feelings of childhood. A teenager might start with cigarette or alcohol-use, move to glue or paint sniffing, or any of a variety of drugs in tablet form and later, perhaps, the injectables. Drug-use leads to additional problems associated with all addictions. The behaviour patterns, peer groups, and lifestyles that go with seeking the means to support addiction lead the survivor into a vicious cycle of further stress and social alienation. Run-ins with the law, prostitution or death could be the consequence. Societies now work at a policy and legislation level to address issues of druguse, homelessness and suicide among young people. Policies targeting individual users aim to reduce usage, as well as to stop and prevent the drug-taking behaviour. However, little is on offer with regard to preceding life events like childhood abuse


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that might have led to the drug-use in the first instance. Intervention strategies often seem to stop at more immediate issues such as housing or harm minimisation. ‘Steve’, 21, was recently hospitalised after a suicide attempt by overdosing. One’s first impression was of quiet despondency and a gentle, pleasantmannered person. He said life held no real meaning. He was unsure what type of help might benefit him now, but medications certainly had not helped in the past. Steve had attended many mental health clinics since the age of 18; the first time, at police insistence, when he had come to their attention for drunk and disorderly behaviour. Steve’s history revealed signs of distress from early years. He was expelled from two schools for unruly behaviour, smoking and drinking. He had a short stay at a correctional centre at the age of 16 for stealing money and valuables from home. No longer welcome at home, Steve then lived in a series of squats. He initially attempted to continue attending school, supporting himself in part-time work. But this became unsustainable and Steve, regretfully, gave up school. His alcohol consumption increased. He developed a drug habit: marijuana, amphetamine and, eventually, heroin. He stole to support his habit. He was charged with burglary. Steve fluctuated between periods of feeling sad and alone when he sought contact and help, and other times when he felt hurt and angry and rejected help. He had, on several previous occasions, overdosed with prescription and other over-the-counter medicines. He often moved his place of residence. With each move, he had to seek out a new mental health clinic for eligibility reasons. Eventually, he stopped regular contact, attending a clinic or a general medical practitioner only if he felt desperate. Steve’s previous mental health case notes recorded a diagnosis of depression. His situation, manner and quiet desperation had generated concern among the workers who had contact with him. During a hospital-admission at the age of 19, Steve had spoken for the first time about his childhood sexual and physical abuse. Although he had always regarded it as the cause for his ‘problems’, Steve had not previously revealed it. He was disheartened when his disclosure didn’t take his treatment in any new direction. Steve didn’t quite know what kind of treatment he sought, but he did know that the antidepressant and anti-anxiety medications he was prescribed had not particularly helped. Steve continued to have constant thoughts of killing himself. ‘Nothing ever goes right’, he said about his life. Young people like Steve are likely to require assistance from several servicestreams—health, as well as welfare. In health, they will need help from drug and


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alcohol agencies, as well as mental health agencies. Each service would need to be knowledgeable about abuse-specific help and, of course, communicate and collaborate with the other agencies involved. Additionally, strategies that benefit a young-adult age group may not be identical with those for older adults. Young people might not be inclined to sit and talk about emotions in an adult style of counselling. Appropriate strategies will need to be specially tailored.

The matter of personality Personality disorders are, essentially, entrenched behaviour patterns that are based on the overuse of certain personality traits. A healthy personality is one that has the option to select from a range of traits. Restriction in such choice, by contrast, is detrimental to the individual, and unhealthy in adult life. Appropriateness or otherwise of a person’s behaviour is, in addition, also culture specific. Categories of personality disorders are determined by the set of traits being overused: anxious, depressive, paranoid or obsessive, for example. A disorder of increasing note these days, perhaps because of its conspicuous self-harm component, is the borderline personality disorder.

Borderline personality This illness disorder is of particular relevance to our discussion because many people with severe borderline personality disorder have been sexually abused in childhood. A person with this type of personality disorder not uncommonly comes to the attention of health practitioners for their longstanding, often striking, sometimes gruesome self-harm behaviour. They are also likely to have difficulty in maintaining long-term relationships: involving either ambivalence, or swings between intense feelings of love and hate. They might also have additional aspects that sit on the border between neurosis and psychosis. Such a survivor is often shunted from one agency to another, not only because of their complex situation, but also because they are often regarded as manipulative or attention seeking. Even though you, as a primary health practitioner, might not be the main healthcare contact for a person with a ‘borderline personality’ disorder, given the current healthcare situation, it is also likely that no other agency, or practitioner is, either. It is also possible that a survivor such as this connects with you for a while. The discussion provided here will give you the rationale for ongoing work with such a survivor should you decide to undertake aspects of it in a collaborative arrangement to manage risk, perhaps with a local mental health team, or a doctor. Chapter 1 noted that although some of a survivor’s adult traits may seem inexplicable to others, they become understandable if viewed in the context of their childhood strategies to cope with abuse.


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Appropriate handling of adult life-situations requires a person to have a range of emotional and behavioural skills. We develop these in childhood and teenage years. The learning curve flattens with age, the process being mostly complete by early adult life. Undoubtedly, we continue to acquire some new skills throughout life, but not at the earlier rate. The adult process is, in the main, one of selecting and adapting from an already learnt range. Chapter 1 also noted that trauma in childhood impacts upon this learning sequence. An abused child has to learn ways of coping not required by other children. The priority to learn abuse-specific survival strategies hinders such a child from developing a broader range of emotional and behavioural skills. Consequently such a child tends, as an adult, to either overuse or use inappropriately, their fewer options. Chapter 5 discussed some groups of behaviours that contribute to a survivor’s personality traits. We considered a survivor’s difficulty to be direct, for instance, and the related difficulty to be assertive. Adult traits of directness and assertiveness develop in childhood and teenage years. But what about an adult who was abused in childhood? Being direct or assertive might have been counterproductive for such a child. The reverse—to please or appease—might have been this child’s necessary coping strategy. As a consequence, such a child develops many ways to please or appease, rather than many ways to be assertive. A certain survivor’s desire to please could directly underpin their difficulty to be direct. Yet, the outcome of this desire to please is often counterproductive: in that the behaviour—or, the survivor—is considered to be divisive and ‘splitting’ by the very people called upon repeatedly to assist. In undertaking ongoing abuse-specific work, personality aspects of each individual are to be viewed in the context of their life story. ‘Heather’, aged 29, had a background of years of self-harm and suicide attempts. She had periodic, but not ongoing contact with different mental health and community health agencies in times of increased distress. Antidepressants and tranquillisers had provided only limited benefit. Heather had been sexually abused by her stepfather. She was uncertain when, precisely, the abuse had started, but the stepfather had come into her life when she was aged about four. She recalled that she’d first run away from home when she was eight. The police took her back on that occasion although she told them about the abuse. They accused her of making up stories. Her mother didn’t believe her either. Heather eventually left home at 17. With no money and nowhere to go, the sex industry seemed her only option. She lived for some years in a series of temporary settings. She used drugs occasionally at that time on a recreational basis. She had been cautious about regular use as several of her peers had died from drug-use. Heather wished she could change her lifestyle, but couldn’t see a realistic alternative.


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While aged in her early and mid-20s, Heather had two relationships, both violent. She sought shelter at women’s refuges on several occasions, but each time eventually returned to her partner feeling sorry for him, maintaining that he needed her. Heather had many admissions to inpatient mental health units for her suicidal intent. Heather seemed devoid of emotion in interview. She spoke of the numerous times she had run away from her childhood home, and the isolation she felt from her peers at school. She spoke of feeling hurt that her mother, even now, could not grasp her childhood reason to run away from home, despite the fact that her mother herself eventually left her partner because of his violence. Heather described often experiencing an intensely distressing sensation— as though she were ‘about to burst out of my skin’. She found relief in cutting herself with a blade at such times. The pain of the gash and the warm sensation of blood helped ease the intolerable sensation. Heather spoke of a deep fear that accompanied her ‘about-to-burst-out-ofmy-skin’ sensation. The fear was one she experienced often in teen age, when she pretended to be asleep: ‘Hoping he would leave me alone. Sometimes he did, other times he did not. It was unending, he would come in while I was having a shower, touching my breasts and my genitals; he would grab my breasts from behind if I was alone in the kitchen.’ People like Heather generally do not have the opportunity to continue in ongoing abuse-specific work. Although their complex mental health needs would benefit from collaborative healthcare arrangements with relevant agencies it, sadly, doesn’t eventuate for a multitude of reasons—her lifestyle, financial circumstances, paucity of emotional resources, and the lack of available abuse-specific expertise. Often such a survivor seems to ‘just coast along, somehow’—many do not.

The issue of insight A person’s capacity to recognise their problem issues and to take responsibility for them were discussed in Chapter 5 as contributing to insightfulness. Such a capacity to reflect on personal issues implies a degree of objectivity. Acknowledging hard truths about oneself is never easy. A survivor’s ability to set internal limits is linked to this. A degree of insight is essential for a survivor wishing to undertake ongoing abuse-specific work for their complex adult health issues. Having their health worker point out problem issues will be insufficient. Survivors who have used denial as a significant coping strategy, for instance, will have a particular difficulty with insight. ‘Joanna’, who was 28 years old, attended a community mental health clinic at the insistence of Protective Services involved with the care of her infant daughter.


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Joanna herself said that she had no idea why she had been referred to the clinic, as she had no particular problems. She was of the view that much fuss had been made over an incident two months previously when she had been found in a phone booth in a street known for its drug trade—unrousable, with her two-week-old sleeping infant strapped to her chest. At waking, Joanna found herself in hospital and learnt that she had been brought by ambulance. She denied any drug-use, maintaining to hospital staff that she had been naturally asleep in the phone booth. As this opening made any assessment difficult, I asked Joanna if she had ever previously experienced emotional illness. She replied that she had been treated some years ago for several suicidal attempts and diagnosed as having a Borderline Personality disorder. She had, however, turned over a new page in life, she said, and was now unwilling to speak of the past. Still unable to start the assessment, I asked if Joanna would allow ‘Sue’ the Protective Services worker who had accompanied her to the clinic, to join us in the room to cast some light on the referral. Joanna was quite happy to allow this. ‘Sue’ told us that child-protective services had become involved during Joanna’s admission to hospital because of staff concerns for the infant’s wellbeing. In ongoing contact, Protective Services became concerned about the parenting capacities of Joanna and her partner, the child’s father. They had grounds to suspect that both had a history of serious drug abuse. They also became aware that during her previous treatment for suicidal attempts Joanna had disclosed a history of sexual and physical abuse during her childhood. Joanna interrupted to contradict this, saying she’d had a normal, happy childhood and that her parents had cared for the infant during her recent hospitalisation. Both Joanna and her partner had insisted at hospital that they continue caring for the baby after discharge. This was allowed, but a court order stipulated that Protective Services was to monitor the situation closely and that Joanna must undergo a psychiatric assessment. Consequently, Sue had initiated the present appointment and driven Joanna to the clinic. The mental health clinic, however, had no prior notification of the court requirement and, with no mandate to undertake enforced assessments, Joanna had to be referred to an agency that could provide this. It was an unsatisfactory and uneasy situation for all the workers involved, but Joanna, herself, remained remarkably unfazed by the sequence of events. I’ve presented this somewhat extreme, but not uncommon, example to illustrate that attempting behaviour change in the absence of personal commitment—such as in the above instance—is not possible in the mode of work described in this book. The issue of the infant’s safety was a separate, clear matter. Joanna was mandated by court order to co-operate with procedures to monitor this. However, she herself


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was not under a court order for treatment or rehabilitation; neither was she psychotic. This meant that she could choose not to participate in any program on offer. Any personal psychological shift—rather than mandated behaviour change— would be next to impossible with Joanna’s level of insight. In such situations one can only hope that time and further life events facilitate some movement within her.


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CHAPTER 8

Strategies and techniques in ongoing abuse-specific work CHAPTER AT A GLANCE Aims for ongoing abuse-specific work Principles guiding ongoing abuse-specific work Content of ongoing abuse-specific work Strategies in ongoing abuse-specific work Techniques in ongoing abuse-specific work Collaborate and network, or refer Worker-related issues

Ongoing abuse-specific work is a complex undertaking when compared with early stages of the work. There is no doubting this. While early work can be undertaken in primary healthcare settings, aspects of ongoing work require specialist expertise. General healthcare workers might feel particularly untrained to provide it. However, this is the crux of the current healthcare scene—namely, that there is not a pool of ‘specialists’ available to the increasing number of survivors who seek abuse-specific help. This chapter sets out guidelines for aspects of such work you might consider providing within the following provisos: • Stay within your training background and framework. • Stay within your competence level. When measures of your client’s risk and coping levels exceed your competence, seek additional input from appropriate professionals for these components. Given these two provisos, it is more than likely that, to provide a survivor with some aspects of ongoing abuse-specific work, you will be in ongoing collaboration with other professionals, each contributing components of a survivor’s holistic healthcare needs.

Aims for ongoing abuse-specific work The aims for ongoing abuse-specific work are twofold: • to help the survivor to deepen their understanding of how past abuse affects current functioning


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• to enable the survivor to develop healthier styles of functioning on the basis of such understanding.

Principles guiding ongoing abuse-specific work The safe space you established in earlier sessions is the milieu that will facilitate the above-mentioned aims of ongoing work. Your empathetic objectivity can be used to advantage to help your client to explore in greater depth the relevance of past abuse to their current functioning. You client’s deepened understanding allows them to see why they persist with certain old behaviours that are of limited efficacy. In turn, this helps them to devise more effective behaviours with your assistance. In ongoing work, interpersonal processes between you and your client are likely to bring up re-enactment issues that will need to be addressed. For instance, you might be at the receiving end of your client’s intense emotional need, or ambivalence. Alternatively, you might note early boundary blurring. Resolving these issues within your interactive space will also provide the survivor with a paradigm for everyday situations. As with early work, this stage, too, needs you to continue monitoring risk and to maintain safety. Additionally, because survivors needing such complex abusespecific work are often also in ongoing mental healthcare, do ensure that the survivor has not dropped out of their mental health follow-up. This can happen quite easily because the survivor might consider their work with you as more relevant. Principles in ongoing work n n n n n n n

Continue to provide a safe interpersonal space. Facilitate exploration of the relevance of past abuse to current functioning. Devise strategies to replace habituated, unhealthy coping behaviours. Address process issues as they arise. Be mindful of re-enactment. Continue to monitor risk and maintain safety. Ensure management of ill-health symptoms.

Content of ongoing abuse-specific work Ongoing abuse-specific work has three components in terms of content: • Disclosure work • Memory work • Rehabilitation.

Disclosure work The disclosure aspect of sessions was discussed in Chapter 6. This aspect continues for as long as your client needs to dwell on their abuse experiences. In ongoing


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sessions, however, disclosure often tends to not remain as a circumscribed topic. Additional aspects of the abuse continue to emerge in sessions in the context of the survivor’s current life events that generate distress. The safe emotional setting with you allows a survivor to stay with difficult and hurtful memories that they might have previously shied away from. You have also, together, put some procedures into place that reassure the survivor that emerging emotions will not overwhelm them: strategies for the survivor to remain in control of the pace of work, as well as techniques they can use to contain distress. All these help now.

Memory work Survivors of abuse often comment that they have only sparse details of childhood memories of abuse. Some hold the view that, if they could actively deepen their memory, they could then get over their ongoing depression, or anxiety, or other consequences of their abuse. Such people could seek therapy to ‘try to know precisely what happened’ to them in childhood. In keeping with this, they might request hypnotherapy, or, for a professional to metaphorically ‘help them to dig out’ their memories. This book does not espouse any approach that requires consciousness-altering methods. As mentioned at the outset, maintaining equality of transactions between survivor and health worker, and a collaborative approach are central to methods endorsed here. The emphasis of memory work described in this book is to help the survivor to deepen their understanding of how past abuse affects their current functioning rather than to establish a ‘complete picture’ per se. The approach to memory work taken in this book—detailed in Chapter 9—is that providing the time and appropriate interactive space for a survivor to dwell on their existing memories allows other memories to emerge if it is healthy for their minds to do so. Such a process of memory-return is often triggered by a survivor’s current life events concurrent with the ‘safe’ interactive work. You might not, as a primary health worker, undertake memory work with your client. However, it is possible that because of their secure and trusting interaction with you, your client dwells more on their existing memories—although they are hurtful—in their own time. Staying with these memories might bring up for the survivor, other memories that were previously too hurtful. This chapter would help you to handle such a situation. On the other hand, it is possible that, rather than a memory, it is a familiar distressing feeling, or an uncomfortable body sensation that recurs for your client. Because you have spent time together on discussing the survivor’s abuse experiences and their body sensations of the time, you might see current parallels before your client does. Making such correlations helps the survivor to recognise the extent to which their current style of coping and functioning is based on their past experiences rather than determined by needs of the current situation.


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Above all, the principle of facilitating the survivor to maintain control over their pace of work assumes importance in memory work. As a consequence, this work does not proceed in an orderly and structured fashion even if the survivor desires it to. Types of memory-return and ways of handling them are discussed further in Chapter 9.

Rehabilitation Even for a motivated survivor, changing an entrenched habit can be very difficult. We noted in Chapter 6, that effective strategies are likely to be those adapted from strategies that have worked in the past for a survivor. Once a survivor is able to see why their habituated behaviours aren’t effective now, they are more motivated to modify these behaviours and to devise new strategies. However, actually changing entrenched behaviour patterns might not be regarded by a survivor as a vital component of getting past the trauma of their abuse. Exploratory memory work, and making links and correlations may be the aspects that initially appear valid. The nitty-gritty of changing behaviour patterns might seem unexciting and unnecessarily tedious. ‘When will I ever get past all of this?’ is an often-encountered question. The answer hinges on how successfully the survivor resolves the aftermath of their trauma. This depends on how successful they are in resolving current life issues. This in turn might depend on how adequately the person uses new and more appropriate responses instead of old entrenched patterns. Changing behaviour patterns becomes important in this context. Rehabilitation principles are useful in approaching chronicity whether in symptoms or behaviour patterns. We apply these principles more readily to other longstanding health issues. For instance, ‘living with pain’, or ‘managing’ pain is a concept used for physical pain. Similarly, substance-use programs use the concept of harm minimisation in long-term management. The principle is just as relevant to longstanding emotional pain and longstanding maladaptive behaviours. In ongoing abuse-specific work, it could be important for a survivor to consider the notion of ‘living with the trauma’ in such a way that it does not stunt the quality of every other aspect of life. Content of ongoing abuse-specific work Disclosure work n Continues to explore the relevance of past abuse to current responses to life events Memory work n Staying with existing memories in a safe way allows the survivor to access further memories that will provide new understanding of their current functioning Rehabilitation n Changing entrenched coping methods n Living with trauma pain


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Strategies in ongoing abuse-specific work Let us now consider the strategies that will enable the above content of ongoing abuse-specific work. Early abuse-specific strategies, as we noted in Chapter 6, hinged on enabling the survivor to cope by helping them to understand their symptoms and experiences in context of their childhood abuse. Strategies in ongoing abuse-specific work are geared to the further level of complexity in disclosure, memory, and rehabilitative work.

Maintain optimal balance of exploration and containment The most important aspect of ongoing work is that a survivor must not feel overwhelmed by the explorations and connections they are making. In other words, a balance between exploration and containment is to be maintained at all times. Optimal balance is one determined by the level of the survivor’s wellbeing. This needs a continual monitoring of risk and vigilance regarding safety protocols. The survivor will need to be diligent in practising their chosen containment technique. You will need to review this periodically. Only then can exploration techniques—to be described later in this section—be continued safely. A healthy balance is also helped by your continued facilitation of the survivor’s control over the pace of work.

Stay aware of interpersonal dynamics In ongoing work, it is particularly important for you to stay aware about interpersonal dynamics emerging between you and your client. Such awareness is needed in any model of long-term work, not merely in a psychodynamic type of therapy. Be aware of the survivor’s potential for re-enactment of the childhood dynamic in a current ongoing close contact, especially in a situation such as that between you, where the survivor is dwelling on past abuse experiences, and old emotions are emerging into their conscious awareness. Discuss aspects as they emerge. Run your observational conjectures past your client. Remember this is a joint process. You are discussing a concern, not making a judgement. Maintaining personal boundaries is crucial. More detail on dynamics appears a little later in this chapter.

Maintaining boundaries It is the worker’s responsibility to maintain boundaries at all times. Blurred boundaries that proceed to intimacy is professional misconduct. While this may seem an obvious statement, we know that, unfortunately, there are numerous instances where boundaries do blur. Trust, the degree of closeness, and the power balance in the interaction between the survivor and their health practitioner are some of the factors that have a bearing on this. Remember, boundary transgressions do not take the form of a clear stepping


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over a distinct line at a particular moment. Situations build up. Misguided reasons and justifications then gradually take hold. There are different types of boundary blurring—not all lead to sexual intimacy. It is the worker’s responsibility to stay vigilant, and to discuss issues with the survivor as they arise.

Vigilance regarding safety Ongoing abuse-specific work is complex. Although it might be expedient to adopt a needs-based approach to tide over a crisis, a pro-active approach is by far the arrangement of choice in ongoing work. Recruiting participation from a practitioner with appropriate expertise—with regard to the survivor’s safety with other health needs—allows your focus to remain on an abuse-specific dialogue.

Collaboration and networking Continual use of the risk and safety protocols described in Chapters 3, 4 and 6 instils your client with self-monitoring routines. Together, you might also be able to foresee specific times of heightened risk. This allows discussion on the need to recruit additional assistance in a pro-active manner. You are probably already very familiar with the next steps. Identify a professional or service in the region with appropriate skills or mandate to assist with the particular type of risk your client faces. This could be a mental health service, alcohol and drug services, or a local GP. Facilitate your client to approach the particular agency, and approach them yourself as well, if needed. In such situations—related to risk level—you might consider an initial joint session that involves you, the survivor and the other agency or worker, to work out a clear delineation of roles. Further occasional joint sessions might also be useful. If the situation, such as a period in hospital, hinders your ongoing contact with your client, discuss how some—if minimal—contact can be maintained while the risk is brought back under control. It might be unwise to discontinue your sessions with the client at this stage of the work. Strategies in ongoing abuse-specific work n n n n n

Maintain optimal balance of exploration and containment. Be aware of, and discuss interpersonal dynamics that emerge within the process. Maintain personal boundaries, and be mindful of re-enactment. Stay vigilant regarding safety protocols. Collaborate and network.

Techniques in ongoing abuse-specific work Techniques required at this stage of abuse-specific work are likely to be complex. This section is not written with a view to making a specialist therapist of every health


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worker who is involved in a long-term way with an adult survivor of childhood sexual abuse. It aims to conceptualise some techniques that a specialist therapist might use in this field of work, in the view that—with some provisos—you might be able to use aspects with your client. However, it is important to bear in mind that, although principles and strategies for early and ongoing abuse-specific work are applicable across professional disciplines, the specific techniques you use will depend on your training background and service framework. Even if you feel unable to personally use aspects of techniques described here, such information might still help you to collaborate more knowledgeably with a therapist involved in your client’s care. In the writing of this section I’ve had to simplify complex processes. Individual schools of practice use technical, or ‘jargon’ terms to do justice to such complexity. These technical terms allow a kind of short-cut communication between practitioners of the same persuasion. But their use—specific to each school of thought—also, unfortunately, can prove to be a barrier to someone who is not a practitioner of that particular school. My simplified account of techniques risks conveying a sense that their use is straightforward. It is not. If you do incorporate some aspects into your own work with survivors, remember to always stay within your competence level. Each time you feel you may be foundering, use the measures that were described in Chapter 6 to monitor your client’s risk and maintain safety. Get additional help if you are unsure. As examples provide a clearer understanding of points being made, the discussion that follows draws on techniques from my practice methods. This does not imply that they are the most appropriate ones. My techniques draw on a combination of psychodynamic, cognitive-behavioural and pragmatic commonsense measures. Exploration techniques are different from containment techniques. Examine your skill repertoire and separate your techniques into these two categories.

Techniques for exploration As we saw, the strategy of staying with a survivor’s existing memories allows fresh aspects and further memories to emerge. Techniques to enable this strategy need to be facilitating in nature. The practitioner’s role here is that of a respectful facilitator. It is important for you to be invited It is important for into a survivor’s traumatic space each time. Intrusiveness is you to be invited generally counterproductive. into a survivor’s traumatic space each time. Intrusiveness is generally counterproductive.


Staying grounded in survivor experience Help the survivor to stay grounded in their experience. To achieve this you, too, need to be grounded in your client’s experience. This can be difficult as it may be easier for the

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survivor to veer into another’s viewpoint than it is for them to stay within their own experience. It is important, though, to note that being grounded in your client’s experience does not require you to endorse all of their views. Your empathetic objectivity is crucial. Your client’s trust has been building since you began this work. You are now at a stage where you are able to point out discrepancies when they arise—between the requirements of the client’s current situation, and how their actual handling of it is more in keeping with their past abusive experiences.

Awareness of personal and interactive dynamics Examples of adult personal and interactive styles that derive from a survivor’s childhood ways of coping with trauma were discussed in Chapter 4. These emerge more clearly in ongoing work as your client speaks about current everyday experiences. Help her/him to identify predominant personal dynamics that colour their everyday responses to life situations. These vary from one person to the next. For a certain individual, avoidance of anger might be central, whereas another person’s strong need to be looked after influences their day-to-day behaviour. One person consciously avoids thinking about traumatic issues while, for another, such avoidance might be a more subconscious process. Yet another person dissociates in the face of a certain type of stress. Similarly, you might note over time that your client’s manner of interaction with others has been influenced by the abuse. For instance, one survivor might interact in a ‘dependent’ kind of way; another, with ambivalence. One person might be inordinately distrustful, another trusts too easily. Inadequate assertiveness could be another’s predominant interactive style, or, taking an appeasing stance. Yet another client has unclear personal boundaries because these were violated in childhood. Generally, it is only in ongoing work that these patterns become apparent. If and when they do emerge, and they seem mismatched to the requirements of the survivor’s current situation, it helps for you to discuss them. Undoubtedly, for a survivor to eventually change such patterns will be hard work. But a survivor can’t even begin unless they can see the mismatch. It is crucial for you to maintain a balance between empathy and objectivity. If your empathy leads you to form a view that is identical to the survivor’s, you might not be able to help them move on. In fact, you are even likely to get caught up in the survivor’s intense emotional need or ambivalence, or both; particularly if you are, increasingly, its focus. Group work can be a powerful mode in this field. It lends itself particularly well to combating stigma and secrecy for a survivor who has felt isolated and ‘tainted’ all her life. Practitioners working with young adult survivors, however, will need no reminding of cautionary aspects in undertaking group work. Various types of self-harm may be used by young adult survivors who have a severe sense of disempowerment, as a means to cope. Self-harm has the potential to be ‘contagious’—in the sense


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that young people who have not previously used this method, adopt it as a viable method when in the company of those already practising it. Another group dynamic to be mindful of is the potential of ‘splitting’ between agencies or workers. This was discussed in Chapter 5. For the survivor, the origins of this type of interaction probably date back to a childhood difficulty to be direct. As noted earlier, it might be more viable for an abused child to appease rather than to confront or be assertive.

Being careful about interpretation Drawing subtle and meaningful parallels between a survivor’s current coping strategies and their past abusive experiences is not an easy technique. Your skill with this technique will become increasingly sophisticated as you continue to spend time with a particular client. However, it is useful to remind oneself that such interpretations remain, at best, conjecture. Your client will take some of your interpretations on board as relevant and pertinent; they will reject others. Or, they might find your observations useful to a certain extent, but not completely. Despite this, your observations differ from comments your client might receive from friends or family, on two counts: • You are making observations while grounded in the survivor’s experience, and • You are making observations with an empathetic objectivity. Comments your client receives from others are more likely to be coloured by the bias and personal issues of that other person.

Body signals The importance of somatic signals was discussed in Chapter 7. Techniques to work with somatic signals are, however, complex and likely to require specialised expertise. Some survivors might opt to undertake such work with a suitably skilled practitioner, who you might collaborate with. Collaboration and networking issues are discussed a little later in this chapter.

Containment techniques Containment techniques used in ongoing abuse-specific work are the same as those used in early stages of the work, and were discussed in Chapter 6. Your client’s skills with anxiety- and depression-reducing techniques continue to improve with practice. Undoubtedly, maintaining disciplinary rigour is often tedious, and an uphill battle. But the reward of improved everyday functioning serves as an incentive. With time and your encouragement, your client grows increasingly sophisticated in registering their mind–body distress signals, and becomes more proficient at their chosen containment techniques.


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Matching technique to suit strategy The techniques you select from your skill set must match your intended strategy. Let us use an example to consider this. We noted earlier that an important strategy at this stage of the work is to maintain an optimal balance between exploration and containment. The following table illustrates how techniques for exploration need to keep pace with containment techniques. The specific techniques mentioned in the table are drawn from my repertoire, and use psychodynamic and cognitive-behavioural principles. Remember, your particular techniques will need to be drawn from your training background and skills. Maintaining optimal balance between exploration and containment Specific techniques are to be drawn from each worker’s training background Techniques to explore Enter survivor space with respect Stay grounded in survivor experience Be aware of personal and interpersonal dynamics Be careful about interpretations Help to recognise somatic signals

Techniques to contain Pick up distress signals Reinforce coping strategies Monitor level of coping Facilitate anxiety-/depression-reducing techniques Enable survivor control over pace

Some techniques lend themselves to individual as well as group processes, while others suit one or the other. Their use in each situation depends on your skills and preferred mode.

Collaborate and network, or refer Generally, if a practitioner has been seeing a survivor for some time, it is safety and risk issues that prompt them to consider referring their client elsewhere. Triggers might be a deterioration in the survivor’s health; increased suicidality, or escalating personality issues, for instance, in the case of someone who has a borderline personality. Sometimes prompts for considering referral are related to the practitioner’s work situation. These might include inadequate support and supervision for the practitioner in the workplace, self-doubts about competence level in this field of work, lack of collaborative expertise, and time constraints. Agency policy is another factor that leads to survivor referral. Some agencies might have a policy not to provide certain types of services, for instance, to someone with substance-use issues, or a personality disorder. Or they might have a policy that allows only a set number of sessions per client. Or they might consider ongoing abuse-specific work to belong with another type of agency or service.


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Collaboration If you have provided a significant period of time to your client, it is likely that you have probably already been collaborating with another practitioner, perhaps with regard to risk management. It would be useful, nevertheless, to also consider further options for pro-active collaboration. Complementary skills provided by the other practitioner might allow you to continue abuse-specific work with your client rather than have to refer them outright. Collaborative options will obviously depend on the type of skills you seek from the other practitioner with regard to a specific client. Irrespective of whether you work at an agency or in sole practice, local options might be preferable, in the first instance. Check your list of local public-sector agencies. Might there be skills available at the community health centre, mental health service, alcohol and drug service, sexual assault or family violence service? In the non-government sector, could your client use help from supported accommodation or residential care? And finally, the private sector might have some, albeit rare, options for affordable counsellors and therapists from various disciplines.

Networking Networks are another immensely useful option in this field of work. Establishing a networking group with other like-minded practitioners allows you to develop your expertise and confidence to work in this field. You begin to realise that you are already providing much of the work. You could form a peer support group with other practitioners who also provide abuse-specific help to clients. Regular meetings allow you to discuss problem issues that arise in the work, as well as provide much needed support. Such a group also provides a forum to share techniques and skills. Networks do not need to remain local and regional. People are generally willing to travel some distance to meet with compatible practitioners. You could periodically have an external facilitator, or invite a guest speaker from either within your local region or outside it. Supra-regional networking could see you recruiting expertise—specialists or specialist units—either for secondary client consultation, or to run abuse-specific training. Collaboration and networking Regional

Supra-regional

Pro-active collaboration for specific clients

Worker/agency with complementary skills

Specialist unit—public sector Specialist practitioner—private sector

Networking for expertise development

Peer support group

Facilitator for peer group Training workshops


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Referral And finally, after considering all the above options, there will still be situations where your decision is to refer your client on. This could be a difficult decision to make, and to implement, if you have been working with your client for a while. You have decided that it is no longer possible to merely collaborate with another practitioner regarding specific issues. You have arrived at a point where you feel you have provided as much as you can to this client. You think your client needs another type of expertise, even if you are unsure what type. Your client might have difficulty in accepting your decision and the reasons for it. Talk this through. Be honest with your client. Couch it as gently as possible, but clarity in your reasoning and your consistency of approach is essential to maintain throughout, and even at this stage. Then comes the task of finding such a practitioner/agency to refer your client to. This, too, might be difficult. You feel your client needs specialised therapy. But you have no way of knowing whether the people on your list will handle your client’s clinical issues as well as their abuse issues. You are well aware that public sector availability of such expertise is extremely limited. You are also aware that going to an agency that has insufficient awareness of abuse issues can be a fragmenting experience for your client. This is why you have until now used the option to collaborate and network. In summary, the situation is difficult, and you can only communicate all of this to your client. You’ve done as much as you can. Referral issues n n n n n

What are the reasons to consider referring your client on? Is it still possible to collaborate on specific aspects rather than refer? Be clear in statements to your client. Where/to whom will you refer? Will the other agency or practitioner handle clinical, as well as abuse issues?

Worker-related issues in ongoing abuse-specific work Given the complexity of ongoing abuse-specific work, a practitioner providing aspects of collaborative care is greatly advantaged by equipping themselves with an awareness of potential psychodynamic issues. Chapter 4 provided some examples of interpersonal dynamics that could develop between survivor and worker, while Chapter 6 discussed issues pertaining specifically to early work. Let us now consider some examples of worker issues in ongoing abuse-specific work. Ongoing work with survivors of abuse places great emotional demands on a worker. Awareness of issues and appropriate handling of the worker’s own needs helps to reduce burnout.


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It is essential for a worker undertaking ongoing abuse-specific work to have access to routine debriefing, support and supervision. Peer discussion and supervision will provide the worker with the opportunity to clarify their dynamics with clients. Some dynamics are important to mention here. The intense emotional needs of a survivor and a potential for re-enactment of their childhood situation, combined with a ‘giving’ but inadequately aware worker could lead to interactions with various degrees of blurred personal boundaries. Considering their client to have few alternatives for help, such a worker, in their commitment, might drift outside their level of competence, and stray from their framework to accommodate their client’s needs. Conversely, however, a worker who is very aware of interpersonal dynamics, but is less aware of abuse issues may not tolerate the survivor’s intense emotional needs. Rather than regard the survivor’s behaviour as a learnt strategy to cope with their abusive childhood situation, such a worker may label the survivor’s behaviour as attention seeking, manipulative, and ‘splitting’. Worker burnout with its outcome of hardened cynicism and inability to empathise are also aspects to be aware of. The previously mentioned measures of debriefing and supervision go a long way to help in each of these situations. You might also consider options beyond a rushed workplace debriefing. Forming a regional or supra-regional peer support group could be one such option. Also look out for training opportunities to meet different aspects of your particular training needs.


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CHAPTER 9

A note on memory CHAPTER AT A GLANCE What is memory? Classifications and terms used A comment on ‘false’ memory Relevance of service frameworks Triggers and the process of memory-return Working with memory

Previous chapters have discussed the topic of abuse memories mainly from a survivor’s healthcare perspective. A survivor rightfully regards their memories as their personal issue. However, a person’s abuse memories might also have an implication for others—their family, for instance, or the perpetrator. With an increasing number of disclosures by adult survivors these days, there is also a growing concern in society about techniques for memory retrieval and implications for proof. This chapter provides a rationale and process of memory work that accommodates such complex issues.

What is memory? The Oxford Dictionary definition of ‘memory’ comprises two aspects: the faculty by which things are recalled to, or kept by the mind; and secondly, one’s store of things remembered. The first, hence, is a person’s capacity for a certain process or task, while the second pertains to items in the memory-content. This fact, that the word ‘memory’ can be used in more than one way, contributes to its confusing and sometimes conflicting usage by health practitioners, as well as others.

Classifications and terms used You have probably come across a plethora of terms related to memory. This can be quite confusing as these terms have varying definitions. Some pertain to the content of memory, others to its formation, others to its retrieval, and yet others, to its verification.


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Usage in healthcare generally depends on a practitioner’s training background. Each school of thought has its preferred classification of memory that is based on a central concept. For instance, a certain classification may be based on the time of origin of memory-content. A memory, in this system, would be categorised as an immediate memory, a recent memory, or a long-term memory. Another classification might have the type of memory-content as its basis. Here a memory would be a verbal—narrative—memory, or a non-verbal—experiential— memory. To understand the implications of using specific terms and definitions of memory, one would need to examine each within its conceptual framework. For instance, the terms ‘narrative memory’ and ‘experiential memory’ pertain to content. Narrative memory, as the term suggests, is available to the person in the form of words; while experiential memory is not. Body memories would be an example of an experiential memory. A memory that is described as either narrative or experiential would obviously not preclude its being immediate, recent or remote. Further, a system that classes memory according to brain region or its electrical/biochemical nature is not necessarily refuting any of the former terms. However, the existence of such a plethora of terms can impede cross-disciplinary dialogue. The following table gives some examples of memory classifications and the terms they use. Memory classifications 1 Pertaining to content n Immediate memory; recent memory; long-term memory n Narrative (stated) memory; experiential memory n Explicit (facts and dates) memory; implicit (sensory) memory 2 Pertaining to formation n Electrical memory; biochemical memory n According to brain region n Related to degree of arousal/stress 3 Pertaining to retrieval n Retained memory; returned (recovered) memory 4 Pertaining to verification n True memory; false memory

We don’t have the scope in this book to examine each of the terms listed above. Relevant texts of each training discipline will need to be sourced. The discussion that follows is limited to aspects that have become relevant to abuse-specific work.


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Memory terms encountered in abuse-specific work Terms such as ‘returned memory’, ‘recovered memory’, and ‘repressed memory’ are used widely these days, both within and outside the health context. As imprecise usage can generate confusion for heathcare purposes, let us consider these terms in more detail. Retained memory pertains to memories of childhood abuse that have been continuously available to an adult survivor. This is to be differentiated from returned memory, which refers to abuse memories that were unavailable for a period of time. Returned memories return after a delay or lag period and are often triggered by a life event. Some people prefer to use the term ‘recovered memory’ instead of ‘returned memory’. ‘False memory’ is a term used by others who question the veracity of the survivor’s memory. It is often used interchangeably, with ‘repressed memory’, a term that poses problems as discussed a little later. Memory terms encountered in abuse-specific work Term

Usage

Retained memory

Continuously available to survivor

Returned/recovered memory

Unavailable during a lag period

False memory

Questions veracity

Repressed memory

Combines psychodynamics and retrieval

A comment on ‘false’ memory While the terms ‘retained memory’, and ‘recovered/returned memory’ pertain to availability of certain memory-content to a survivor, the term ‘false memory’ is by contrast, a term that primarily questions the veracity of a survivor’s memory. That it is often used interchangeably with ‘repressed memory’ clouds clarity. The term ‘false memory’ also presses emotive public buttons with regard to childhood abuse. As noted earlier, ‘memory’ has two components—the faculty, or means to either process or keep memory; and, secondly, the contents of such memory. The term ‘false memory’ refers to the latter—a survivor’s memory-content. However, it also includes the adjective ‘false’. This term is used by persons—other than the survivor—who consider the survivor’s memory to be inaccurate or false. The term may, additionally, imply that the individual has intentionally altered or falsified the content of their memory. Without doubt, persons other than the survivor, such as listeners, onlookers and law enforcement and justice agencies have the right to an opinion that the survivor may be lying. But another’s opinion of a survivor’s memory—implicit in the word false—should not be included in a single term pertaining to the survivor’s memory-content. The term ‘repressed memory’—also used to denote a survivor’s memory-content, poses different problems.


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‘Repression’ is a technical term that refers to a type of subconscious psychological mechanism. It contrasts with suppression of emotions, which is regarded as a conscious mental mechanism. Both are part of a theoretical construct often used to explain non-availability of emotions to a person. In this light, to combine two disparate words—repression (a hypothetical process to explain a lack of emotion) and memory (referring to processing and content of specific material available to the conscious mind)—into the unified term ‘repressed memory’ is not only confusing, but inaccurate as well. If the intent—in the term’s usage—is to indicate that a specific memory, which was previously not available …the issue of now is, it is better stated so. Unambiguous terms such as veracity should be ‘returned’ or ‘recovered’ are to be encouraged in abusekept separate from a specific work—for memory that returns after a lag period. term pertaining to a Digressing a little, it is worth reiterating that the survivor’s memory. phenomenon of returned memory is far less common than that of retained memory. As to the interchangeable use of the terms ‘repressed memory’ and ‘false memory’, as discussed above, the issue of veracity should be kept separate from a term pertaining to a survivor’s memory.

Relevance of service frameworks The relevance of service frameworks to abuse-specific work was discussed in Chapter 2. We noted how a healthcare framework differs from a justice, or welfare framework with regard to help a survivor is given. Chapters 5 and 7 discussed complex issues that underpin mental ill health of survivors, requiring them to address past abuse as part of their health process. The exploration of abuse memories that such a process might involve lies within the realm of the survivor’s personal rights. However, if a survivor’s process impacts on another person—for instance, if they decide to confront the perpetrator—they are moving out of their personal health realm, and into a social realm. The latter has norms and laws that cover all aspects of society. A justice framework protects the rights of all individuals, with everyone having the right to be regarded as innocent until proven otherwise. A health worker needs to make this clear to their client. Notwithstanding the above, Chapter 7 also noted that it is counterproductive for a health practitioner involved in the mental healthcare of an abuse-survivor to adopt a selective ‘legalistic’ approach to the survivor’s abuse memories. Judgements are a matter for the justice system, and are guided by a framework other than that of healthcare. A survivor will need to make informed choices as to whether, and when they wish to go down a justice-seeking path. A survivor who has decided to press charges against their childhood perpetrator, for instance, will need to know that to make a ruling, the law requires a perpetrator’s guilt to be established beyond reasonable doubt. There are other situations, too, that


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might take an adult survivor on a path of seeking justice—professional misconduct by a therapist, for instance. Boards that monitor ethical standards of professionals generally use balance of probabilities criteria for their disciplinary rulings. Undoubtedly, working with abuse memories can be fraught. But, clarity regarding differences between various frameworks allows a health practitioner to stay within their own framework if they undertake aspects of memory-work with a client. A worker’s clarity and use of unambiguous terms also helps their client to understand these parameters.

Triggers and the process of memory-return Whether a certain child will retain continuous memory of their abuse depends very much on her or his emotional capacity to handle trauma. This, in turn, depends on the supports and strengths available to the child at the time, as well as later. More adult survivors have some memories—rather than none—of their childhood abuse, even if these are fuzzy. For some, though, memories could return after a lag period. Both groups might experience memory-return in adult life. The first group experiences clearer and new detail of existing memories, while the latter have return of ‘new’ memories. Both types of return generally occur at a life stage when the survivor is better able to cope with the memories. It is as though the memories no longer need to remain inaccessible or fuzzy.

Triggers Generally, such a return of abuse memory is triggered. A trigger might be an overall experience such as a life event, or it might be a more circumscribed stimulus in any one of the five senses—sight, sound, smell and so on. The trigger is not always an unpleasant one. A positive life experience such as being in a good relationship after a series of abusive ones, or the birth of a child, is a not-uncommon life situation that facilitates memory-return. A survivor might be unaware that a bout of old, familiar distress is being triggered by a current event. It helps them immensely to know this, and to be able to identify the specific current trigger. Memory-return will then no longer seem as unpredictable. Seeing why the abuse memory returned at this point in time lifts a person’s sense of powerlessness within it. It also helps the survivor to work out ways to deal with the triggering situation, which in turn helps to regain a sense of control.

Process of memory-return Memory-return does not occur in the form of a sentence such as, ‘My step-father abused me’. It is invariably a complex, experiential process involving several facets of mind–body function. The now well-known form of flashback is a vivid snatch of memory involving more than one sensory modality. Other forms of memory-return include dreams, dream-like states, and other body experiences. Somatic aspects of memory-return


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can be registered in any of the five senses of sight, hearing, smell, touch and taste. A survivor may smell the childhood environment where the abuse occurred, for instance, or a certain bodily odour. Other ‘return’ perceptions could involve internal organs, or a whole-body experience that defies easy definition, for example, ‘I feel I am about to disappear’. Survivors who have always retained some abuse memories could experience a sudden clarity and vividness of their memory, or they may experience a partial and fragmented return of memory details. Survivors with no memories for a period, too, could experience either a sudden and complete return of a full memory, or a partial and fragmented return. The memory work to be discussed in this chapter pertains to fragmented return in survivors with retained memories. All forms of memory-return described below are generally unpredictable and invariably immensely distressing.

Sudden clarity of retained memory Hazy retained memories of abuse could become suddenly vivid for a survivor. The example below illustrates a retained memory that was triggered into focussed clarity. ‘Toni’ described an ‘absurd’ fight with her brother. Over the past few months, she had been increasingly irritated at his manner of slurping tea. She tried indirect comments, sarcasm as well as direct requests to stop it, but he just paid no attention. One day she got ‘absolutely fed up’ and as each yelled at the other, he asked why it bothered her so much. Toni yelled back, ‘Because it reminds me of that dirty old man and the things he did’. Toni was almost as shocked at her words as her brother. Toni had been abused by a childhood neighbour, who had taken her swimming with his own children, and abused her while in the pool. Toni had always had dim memories of these events, but had not, as an adult, ever thought consciously about them. It came back to her with great clarity during the ‘tea slurping fight’ with her brother.

Sudden and complete memory-return after a lag period As noted earlier, some survivors might have no abuse memories for a period. Some among this group experience a sudden and complete memory-return. This, although rarer than with other forms of memory-return, is a dramatic, almost catastrophic type of event, for the person experiencing it. The survivor is left greatly distressed, puzzled and confused. They might be unable to find appropriate words to describe their experience either because it makes no sense, or because it generates painful emotions that are safer kept at a distance. ‘Annie’ was a youth leader at her church. Once, while away on camp, she had ‘a massive’ nightmare. A co-leader sharing the dorm shook her awake.


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Annie felt physically unwell for the next couple of days; others remarked that she seemed disoriented. Although, later, she had only a hazy recollection of the camp itself, Annie was able to give a clear and vivid description of her nightmare: of sexual abuse by a family friend during a certain childhood period when she’d participated in many Brownie camps. She’d had no memory of the abuse in intervening years. It returned fully formed in the nightmare.

Partial and fragmented memory-return after a lag period For a survivor who has had no abuse memories for a period, this type of memoryreturn is more common than the complete return of the previous example. Memory-return here tends to be a gradual one over weeks or months. In the example that follows, the return of some memory fragments were triggered by specific life events, while other memory fragments seemed to fall into place because the survivor could reflect in a safe therapy space. ‘Marie’ sought help for increasing panic regarding recent experiences she could not understand. They began some months previously during an episode of painful sexual intercourse with her partner. Marie thought she heard bars of classical music, although there was no music actually playing at the time. It also seemed a very familiar piece. Her panic subsided in a few hours on that occasion, but the experience left her puzzled and distressed for several days. Some weeks later, while preparing her evening meal Marie identified the music as a piece that had been played repeatedly in her childhood home. At this realisation, Marie experienced another sudden surge of panic. This time, she crawled under the kitchen table and curled up on the floor. The hard surface of the floor felt safe and reassuring under her side. She felt very small in comparison to the legs of the table, and once again, she ‘heard’ the bars of music.

Working with memory As indicated in the preceding discussion, memory work with the majority of survivors occurs in the context of existing memories. It is, in essence, a type of exploratory work, the principles and strategies and techniques of which were covered in Chapter 8. As noted there, memory work with a survivor takes time. It is also a specialised field of work requiring complex therapy skills. This section is written not with a view to guide a primary health practitioner to undertake such work, but to complete the understanding of abuse-specific work presented in this book. It is unrealistic to expect to undertake memory work of the type discussed here, within the limited number of five, ten or even 20 sessions that some agencies are able to provide a survivor. Undoubtedly survivors are helped with other aspects within such time limits, but this type of memory work is likely to take longer.


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This book does not endorse consciousness-altering techniques in memory work with survivors for two main reasons. First and foremost, the power gradient inherent in many consciousness-altering methods makes it difficult to maintain the equality of transaction essential to abusespecific work. The second reason is relevant to a justice setting. Should a survivor decide to press charges against the perpetrator, the legal framework could view a memory returned during an altered state of consciousness as not a ‘true’ memory. Undoubtedly a survivor could choose to use a technique such as self-hypnosis as a stress-reducing method. But combining it in a session with memory work may become problematic later in a court context. As with ongoing work discussed in Chapter 8, the aspects of memory work discussed below draw on my practice framework. Other therapists might use somewhat different techniques.

Could a survivor doubt their own memories? The short answer is yes. Some survivors do doubt their memories at certain times. ‘How believable are old memories?’, ‘Am I sure?’, ‘What if my memory is playing tricks?’ are not uncommon thoughts. Even a survivor who has always retained abuse memories could begin to doubt them upon finally deciding to ‘do something about it all’. A secret that has been buried for many years might suddenly seem unbelievable when viewed in the cold light of day. For instance: ‘Could he really have done that to me?’—about the perpetrator who was a trusted person; or ‘If she didn’t see what was going on, then, maybe it didn’t happen’—about a nonoffending family member. Methodical memory work that remains grounded in the survivor’s experience allows sufficient detail to emerge over time, clarifying doubt.

Survivor control over memory-return Survivors experiencing fragmented memory-return may feel buffeted about by it. They feel at the mercy of their subconscious. Many use instinctive behaviours to achieve a sense of control over their return process. ‘Michelle’ described consulting a hypnotherapist the previous month for help to quit smoking. The incident she described occurred in her third session. At a certain point in the session she felt her right arm levitate slowly; she had a vague awareness of her left hand resting lightly upon her thigh and the solid reassurance of the couch beneath her. Suddenly an overwhelming sob rose in her chest. Caught in a whirl of panic, she struggled to surface from the hypnotic suggestion and emerged gasping. She was certain that this distressing experience was somehow related to her childhood.


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This was not the first time Michelle had experienced this panic. She had stopped hypnosis five years earlier after a similar experience. At that time too, she felt she had been ‘close to knowing something’. She had not the faintest idea what that ‘something’ might be. She was certain, however, that whatever it was would be ‘all be too much’ for her. Following the recent panic Michelle decided to explore its origin. She came to me specifically seeking a process that would not use hypnosis or other mindaltering techniques. Michelle’s containment strategy was an instinctive one. Conscious containment strategies and techniques, such as those described in Chapter 8, are an essential part of memory work. They help a survivor to feel more in control over their process of memory-return.

One step at a time Memory work needs to be meticulous, each step should stem from the previous one, avoiding theoretical leaps and shortcuts. ‘Beth’ was in therapy for longstanding periods of depression. A counsellor she had previously seen for an eating disorder had suggested that it could be related to childhood abuse, but Beth herself had no memories of such abuse. A few months into therapy, Beth mentioned that a visit to the dentist generated a particular kind of intense fear. ‘What sort of fear?’ I asked. ‘It’s when I have to have to open my mouth wide,’ Beth said, ‘something about the way my jaw muscles need to be stretched. That’s the fearful part’. ‘What comes to mind about it?’ ‘I think of childhood sexual abuse. But, as you know, I have no memories of that [happening to me].’ I said that to me, this seemed a somewhat theoretical interpretation. There was longish pause during which I began to sense some growing emotion in Beth. I had a sense it could be something like fear. I verbalised this. ‘Mm,’ said Beth, but remained silent for a while longer before eventually saying, ‘I remember a time when I was about eight years old, I’d be scared to go to bed. I’d yawn and yawn, and then be scared to go to my room, in case my jaw got stuck’. Speaking about it increased Beth’s current anxiety even further. Her voice got choked. I commented that, to me, this explanation sounded a more grounded— and less theoretical—possibility than the other. Beth then spoke of her family situation of the time, and her school life. Dwelling on stresses during that childhood period allowed her current anxiety to pass.


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It would have been fruitless and even dangerous to continue with discussing the theoretical possibility of abuse that Beth raised. The more accurate clue to follow— that of incessant yawning—was indicated by Beth’s emotionally choked voice and minimally heightened anxiety. Identifying the trigger for Beth’s recent fearfulness allowed her anxiety to ease. It also demonstrated to Beth that identifying ongoing triggers could be beneficial. It is relevant to note that the above interaction did not return to the issue of whether she was abused.

Staying grounded in survivor-experience The step-by-step approach of memory work is assisted immensely by staying grounded in a survivor’s experience. Sometimes this leads to additional memory details, while at other times it helps the survivor to understand incomprehensible phenomena and sequences of behaviour. To stay within a survivor’s experience the therapist often needs to clarify details that the survivor might initially consider inconsequential, irrelevant, or, just plain embarrassing. However, if the survivor regards this interaction as intrusive, the exercise becomes counterproductive. It takes time to achieve a facilitatory style optimal to each survivor. As sessions continue, the therapist learns to read each person’s unique subtle, verbal and nonverbal messages. The example that follows is complex, with issues relating to the phenomena of dissociation and regression. It illustrates that much of memory work is a methodical way of enabling a survivor’s clarity regarding events and emotions. Processing their current emotions related to past abuse allows further memory-detail to return to the person. This might occur either in the session, or in the person’s own time and space. New memory detail is not the sole purpose of such a processing. The survivor’s enhanced understanding of present and past experiences helps them to resolve longstanding issues. ‘Mandy’ came very distressed to a certain session. I’d known that she had attended a cousin’s wedding during the week; the occasion of a family gathering was not something Mandy had looked forward to. ‘It was a disaster,’ she said, ‘but I don’t regret what I said’. Mandy’s recounting of the wedding was hesitant, and difficult to follow, but I did not interrupt. ‘Then I went and apologised to Peta’, she said. ‘I spent so much of the evening apologising. But I’m not sorry. I only regret that I said it at the wedding. I don’t regret what I actually said. On the other hand, maybe I’m all wrong. I don’t know why I say these things. Maybe I should not have said anything at all.’ Her rushed flow ended. ‘Maybe you needed to say what you did,’ I said, even though I didn’t as


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yet feel I had a handle on her situation. ‘Maybe you’re only questioning it because of how others reacted.’ Mandy’s opening remarks had suggested to me that she was, perhaps, having difficulty in disentangling her own position from that of others. In which case, by apologising, she would be validating their viewpoint, rather than her own. I had also worked long enough with Mandy to know that she invariably doubted her own viewpoint, however valid. In my comment, I hoped to convey an overall encouragement and also draw attention to the need to be aware of her own emotional position; not merely measure situations by others’ responses. Mandy continued, ‘David thinks I should tell Rose about Robert. I can’t though; it would kill her. I can’t remember much of the evening. David says I said all these things.’ Mandy’s words were indistinct, but her tone conveyed the overall impression of a self-critical murmur. Some of the names she mentioned—David being her partner—were familiar to me, but not others. Mandy was now even more distressed, and crying openly. She pulled her legs up on the chair and hugged her knees. I leant towards her with a box of tissues. She reached out and took one, then sat hunched, crying. After a little while, I said, ‘Mandy, I didn’t place some of those names. Who is Peta?’ ‘My cousin. She’s Rose’s daughter.’ I’d known that Rose was Mandy’s aunt, whose husband, Robert, had abused Mandy in childhood. ‘Do they know [about the abuse]?’ I asked, assuming that the it she referred to at the wedding related to the abuse. ‘Peta knows, her mother doesn’t’, replied Mandy. ‘David thinks I should tell her.’ Pause. I considered two options for this stage of the session: either to focus on her disorganised thought sequence, or, alternatively, on her self-critical statements. I decided that the first option would help Mandy to be more focussed. I would not have taken this option—a more active one on my part—in an earlier session, as it would have interrupted Mandy’s recounting of events and hindered her expression of emotions. However, on this particular day, I felt that my questions would serve to ground her. I also thought that my knowing exactly who these people were and how they fitted into the evening, would help her. ‘Was it a big occasion?’ I asked. ‘Yes.’ ‘Perhaps you could describe it to me.’ I explained that visualising the evening would help me to follow her


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experience of it in greater depth. Mandy thought this was fair enough and described the restaurant, seating-specifics of their group, where she sat and beside whom. Several minutes were taken up with chunks of specific information from Mandy with occasional prompts from me for details. Only then did we return to the distressing events of the evening. Mandy, by now, was nowhere near as fragile as at the start of the session. ‘It all really started with Becky [Mandy’s younger sister],’ she said. ‘The boy she was with, went on the dance floor with Peta. They were carrying on, so I went up and said to him not to bother with my sister any more. Then Rose came up and said, “She’s a bitch”.’ ‘Who did she say this about?’ I asked. ‘Her daughter,’ replied Mandy. ‘Then I said, “This whole family is fucked”. Next, I’m apologising to Rose. I’m like apologising to everyone after that. It was awful. Then Robert stands up to thank every one. Peta interrupts and says, “Except the bitch”, meaning me. Next thing, I’m outside. Don’t know how I got there. David’s behind me. Then Robert’s coming towards me. I say, “Don’t come any closer or I might say something I regret”.’ ‘Where was this?’ I asked. ‘Outside the restaurant’, Mandy replied. ‘David and I walk off. But I have to go back for my bag. David waits outside. When I come out he’s not there. I think, “Shit, he’s gone”. He’s only in the toilet. But I don’t know that. I start walking. Then I’m in this park. I don’t know how long I’ve been wandering. I can hear David calling. I wet myself. It was terrible.’ Mandy sat quiet for a while. However, she seemed to be coping better than at the start of the session. Also, unlike in many previous sessions, she did not seem to be dissociating. The mood of the silence seemed to me, a respectful acknowledgement of the heaviness of the event. ‘I am not distressed about the fact that it happened’, she said finally. ‘I just think it was terribly sad [that such a thing should have happened].’ I knew she was referring to her loss of bladder control. ‘You’re right’, I said, reiterating the wisdom of her words. ‘It is sad.’ Then after another longish pause Mandy said, ‘I used to wet the bed all the time, as a child. Now I think I know why.’ The session could have proceeded in one of two ways at this point. We could have stayed with her new understanding of bed-wetting as a child. However, I considered it more urgent that Mandy understand her recent experience better. We had, on several previous occasions, discussed Mandy’s periods of dissociation but not, as yet, the phenomenon of regression as this incident seemed to indicate. So when I sensed Mandy’s readiness to continue, I verbalised my understanding of the episode. I began by observing that although Mandy felt she could not remember much of the evening, the fact that she was able to recount such specific details indicated that only parts were lost to her despite the hugely stressful nature of the


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event. It followed that she had dissociated only periodically. I also reminded Mandy that such a clear recounting of distressing events would not have been possible for her in earlier sessions. I then commented on her loss of bladder control: that she had possibly regressed to a child-like state. Not finding David might have been the final straw while she was in a very high level of anxiety. As session time was ending, we reviewed her routine anxiety-reducing practices. This brought a rueful admission that Mandy had not in recent weeks been as regular as she could have been with tae kwon do, her preferred technique. I also observed that if Mandy had recognised her very high anxiety levels earlier that evening, she might have been able to put appropriate strategies into place at the time. Discussion of these, however, had to be left for the next session. It is useful to come up with hypothetical strategies even after the event. Survivors invariably use them as a template for future use. Safety measures are likely to be a combination of strategy and cognitivebehavioural techniques. In the above example, for instance Mandy might have tried some breathing exercises during the evening, or she might have asked David to stay close. Having said this, it is important to acknowledge that to actually put these safety measures into practice on such an evening would have been a huge ask. Nevertheless, such ability can be a goal to aim for in the future. To summarise, that the session remained firmly grounded in Mandy’s experience of the family event allowed her to work through complex emotions related to abuse issues.

Making links Memory work helps a survivor to make sense of their sometimes confusing responses to current life events in the context of their past abuse. The process, though, can be tedious, and shortcuts might seem tempting. These are, nevertheless, to be avoided. ‘Nicola’ had much knowledge about long-term manifestations of childhood abuse, but no specific memories of being abused herself. Insightful and articulate, she was also aware of the importance of moving cautiously in therapy. She came into one session panicked about her acutely worsened eating pattern. It needed some kind of urgent intervention, she felt. None of the techniques that had benefited her previously were helping now. She ate large quantities of any food that was in the house, to the point of experiencing stomach pain. It was her alternative to cutting herself, she said. On the previous day, Nicola had experienced an intense desire to be held. So she sat rocking in front of the telly for most of the day. It helped a little, but by doing so, she felt she was ‘giving in’. She said she was scared she might be going mad.


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‘What’s mad about rocking in front of the telly?’ I asked. ‘It isn’t just the rocking,’ Nicola replied, ‘I heard children crying’. She sounded afraid as she said this. So I asked her some questions to determine whether the phenomenon could have been a psychotic hallucination. It wasn’t, and I said so to Nicola, who then sat quiet for a bit. Nicola then proceeded to describe a new childhood memory that had come to her the previous week. It was of her mother saying in a gentle voice, ‘Come, let’s wash you up now’. This sentence, too, had repeated within Nicola’s head in the past week. Nicola’s tone of voice and manner in describing this memory had a certain quality that struck me as familiar from another occasion, many sessions previously, when she described a voice within her head saying, ‘I haven’t finished, little girl’. I raised this with Nicola. ‘I wonder,’ I said, ‘if this sentence is somehow related to that other sentence you described some time ago as repeating in your head [I paraphrased it so she knew which one I meant]’. Nicola calmed visibly at my comment, as though something had jelled. This intervention reduced Nicola’s panic dramatically. I had placed the two sentences—verbalised several months apart—adjacent to each other, for Nicola to examine a possible linkage. She did not, however, choose to explore the content of either sentence in the session. Instead, she opted to discuss her fear connected with her experience of the ‘crying children’. Nicola identified that it was the fear she was going mad that had caused her eating to go out of control. Understanding this sequence proved to be an effective step towards containing her fear, and her eating episode. It is important to note that no interpretation of the existence of abuse or otherwise was made in this session. Nicola and I had, on many previous occasions, discussed the danger of such an extrapolation in the absence of specific memories at this time. The cardinal principle in this session was to understand the basis of Nicola’s current experience. Links were made carefully, ‘one step at a time’. Interpretations, in this light, needed to be cautiously courageous.

The whole truth? Survivors may embark on the process of abuse-specific healing with an expectation of regaining a clear picture of childhood events. Some survivors do achieve sufficient completeness of their memory picture, but for many others this may not be possible. ‘Annette’ had been attending nearly a year of weekly sessions for depression. A reflective and articulate woman, Annette had a successful career despite periods of feeling emotionally low, chronic sleep problems and much physical ill health.


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Annette had sought therapy after experiencing a fragmented return of abuse memories that involved several perceptual senses. ‘I don’t seek to blame, only to make sense of it all for myself’, Annette had said in assessment. ‘I need to understand.’ Further fragments returned during the course of her work with me. One such was a frightening sensation of pressure on her shoulders, as though large hands held her immobile. From the comparative size of the hands to her shoulder, she deduced that she must have been very young at the time. The experience was accompanied by a stomach sensation of ‘a gnawing feeling of total emptiness’. It was a sensation she’d frequently experienced during teen age, when suffering from an eating disorder. With time, she pieced together the significance of many of the sensations and feelings that had puzzled her over the past years. ‘I may never know the whole truth’, she was to say eventually. Survivors like Annette may, in their healing process, place more emphasis on putting the abuse behind them than on recovering clear memory sequences. Many others seek the reverse. Complete memories are not always possible. Neither are they always essential for healing. However, the opposite notion, ‘forget it and get on with life’, may not be ideal either. Each survivor has an individually optimal level of memory recovery. It is one that allows them to put their abuse behind them in a healthy way, and enables them to move on in life.


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CHAPTER 10

The social context of abuse-specific mental healthcare CHAPTER AT A GLANCE The issue A longitudinal view Policy development and research The current situation So what can be done?

Child sexual abuse is a topic that impresses itself on the billboard of public awareness with regular frequency. Paedophile rings, clergy abuse, institutional abuse, incest and the issue of bringing perpetrators to justice are now the focus of lobby groups, justice systems and a concerned public across the world. Increasing awareness of the magnitude of the issue has led to a concerted effort, across international borders and cultures, to stop and prevent such abuse. The impact of sexual, physical and emotional abuse on the health of a child is not, and has never been in doubt. World Mental Health Day in 2002 focussed on the effects of trauma and violence on children and adolescents. However, the situation is very different for adult survivors of childhood abuse.

The issue The adult mental health of abused children, unfortunately, gets nowhere near the acknowledgement that should rightfully follow. It was only in 2002 that the World Health Organization, in its first report on violence, called for public health systems to take on the consequences of violence. In Australia, as in other developed countries, although increasing numbers of adults have been disclosing their childhood abuse over the last few decades, specifically appropriate mental healthcare is not easily available.


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A longitudinal view So why do adult survivors of childhood abuse struggle to find specific help? The answer is complex. The social context, as well as the nature of the issue, has a bearing on this. The 1960s and 70s, we may recall, were times of considerable social change. People agitated for women’s rights and human rights, and against war. Social, economic and political factors of the period brought changes to society’s views on a range of issues: children’s and women’s rights, women’s roles, types and role of families, sexual norms. Sexuality became a more open issue. This was the social milieu in which people—initially women and, later, men— began to disclose their childhood abuse. A slow start in the 1970s became, by the end of the century, a flood. Disclosures required personal courage for there was still immense social pressure to stay silent. Several types of lobby groups formed, general, as well as more clearly defined ones: people who had suffered clergy abuse, for instance, or those who had experienced institutional abuse. Individual survivors also began to consciously consider what bearing their past abuse might have on current health. Although they might previously have done this in private, and with shame, they now did so more openly. The 1980s and 90s found survivors seeking help for health problems that they considered to be linked with past abuse, even though they did not always say so clearly. They approached different types of health professionals for their emotional, behavioural and psychosomatic concerns. Some disclosed past abuse to these health professionals, while others merely stated the health concern without referring to their childhood abuse. Health professionals were, at the time, mostly unaware of specific health correlations of past abuse. Survivor disclosures, consequently, did not necessarily result in abuse issues being explored. Survivors were likely to obtain, in this period, more abuse-specific content from self-help groups and personal workbooks than from their health professionals.

Healthcare in the 1980s The public health sector of the 1980s comprised community centres and hospitals that functioned as two separate fields with little communication and few protocols to link them. Although the reality of child physical abuse had entered healthcare awareness in the 1960s, sexual abuse had not—even in the 1980s. With impetus from the women’s movement, some stand-alone women’s health centres had been established by the late 1970s, as had the first rape crisis centres—later to be called centres against sexual assault—and centres for help with domestic violence and incest. The latter two seemed to evolve, each in its own distinctive culture and model of service, maintaining only tenuous links for many years with mainstream health services. Each provided sessions mainly in a crisiscounselling model, generally limited to a few sessions per person because of funding considerations. These agencies, however, took on, in addition to help for individual


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clients, the important roles of lobbying on behalf of survivors, advocacy, and that of community education. Public sector mental health services, by contrast, remained disinterested in the relevance of past abuse to the current mental issues of many of their clients. In the private health sector, general medical practitioners were ill sensitised to adult issues relevant to childhood sexual abuse, while many psychiatrists providing psychotherapy remained influenced by theories that negated the abuse experience of survivors. All in all, an adult survivor in the 1980s trying to locate a knowledgeable ear had to navigate a fragmented terrain. Expertise and healthcare relevant to their abuse was mostly unavailable. Slowly, however, individual health practitioners, hearing numerous such life stories from survivors, began to search for concepts and techniques specific to survivor needs. A groundswell of community workers, like survivors themselves began with scant funds to attempt to shift entrenched health policies and the culture of silence. The survivor healthcare push of the 1980s had distinct grass-root origins.

Developments in the 1990s So what did the 1990s bring to this field of work? First and foremost, the disclosure rate by adults showed no signs of abating. In fact, it increased. Initially, professionals made little distinction between the sexual assault of rape suffered by an adult, and the long-term consequences of childhood sexual abuse. Help-strategies, consequently, that were available to a survivor at specialist ‘sexual assault’ and ‘domestic violence’ centres continued to focus on ‘disclosure’ and shortterm work, modelled along rape-crisis lines. Limitations on the number of sessions that could be provided to a survivor at such centres—determined by funding rather than by survivor need—remained a relevant factor. Understandably professionals at these agencies amassed expertise in short-, and medium-term abuse-specific work. Public mental health services over this period continued to disregard the relevance of childhood abuse for a significant number of their clients. Drug and alcohol services were similar. Even when these services did acknowledge abuse as a relevant issue for a client, they did not consider themselves to have the responsibility to deliver abuse-specific help. Both services tended to regard such a role as belonging with agencies dealing with sexual assault or domestic violence. But these latter agencies, obviously, did not have the expertise to handle complex needs of survivors with mental illness, psychosomatic illness, or substance-use issues. It remained unacknowledged among health professionals in general that the principles underpinning long-term psychotherapy are not identical with those for short-term crisis counselling. This is a factor of major relevance to survivors with long-term mental health issues.


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Also unacknowledged, was that survivors approaching ‘sexual assault’ and ‘domestic violence’ services have a The continuing central somewhat different priority to those who approach general issue, though, was health and mental health services. The former primarily that private sector seek help with regard to their abuse, while the latter expertise was not primarily seek assistance for ill health. affordable to the What about the private mental health sector of this majority of survivors period? This, after all, is the sector that provides most of trying to cope with the longer-term therapies in Australia. disabling mental ill Very briefly, disclosures from adult survivors led private health, personality, or therapists from various training backgrounds—social work, substance-use issues. psychology and psychiatry—to respond on an ad hoc basis. Gradually an understanding built up, of long-term mental health issues of survivors. The process was slow and the body of knowledge remained ‘hands-on’ and mainly localised to individual settings, or practitioners. ‘Trauma therapy’ that developed in North America did not, initially, catch on to the same extent in Australia and in any case, addressed only some abuse-specific needs of adult survivors. The continuing central issue, though, was that private sector expertise was not affordable to the majority of survivors trying to cope with disabling mental ill health, personality, or substance-use issues. Meanwhile, a system other than health became involved with survivor health issues—the legal system. It may be recalled that Post Traumatic Stress Disorder— commonly referred to by its acronym, PTSD—owes its legitimacy to the justice system. The term, created in North America in response to the health needs of Vietnam veterans, eventually widened to include all form of trauma, including abuse. On the basis of being victims of crime, abuse survivors in Australia became entitled to access a few sessions of ‘trauma counselling’ funded through the justice system. These sessions are generally ‘contracted’ out to private practitioners. The rationale for such funding seems to be modelled along the lines of grief or crisis counselling. Little consideration is given to the fact that a survivor who has used selfharm, for instance, or substances, as a coping strategy for most of their young-adult life, is not going to be ‘cured’ with six or ten sessions.

The primary healthcare setting Primary healthcare services in Australia are provided, as we know, by practitioners from a variety of training backgrounds in: 1 the public sector—in community heath centres of urban, regional and remote areas 2 the private sector • by general medical practitioners whose services are part-subsidised by Medicare • by individual practitioners from a variety of training backgrounds.


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How did survivors fare in these settings over the same time frame? The final two decades of the twentieth century saw an increasing number of disclosures by survivors to primary health practitioners. It is, however, of note that survivors did not disclose as readily to their local doctors as to other health professionals. Symptom worsening and concern for client safety led community health workers to refer survivors to GPs or mental health clinics, who, in the main, did not address abuse-specific issues. This led to the revolving-door cycle referred to in earlier chapters of this book.

Policy development and research Some signposting with regard to policy development in the final decades of the twentieth century would be relevant. The Human Rights and Equal Opportunity Commission Act was passed in 1988. Law reform from the 1980s onwards saw various states and territories introduce mandatory reporting of child abuse, well as changes to legislation concerning adult domestic violence. The report Our Homeless Children, and the National Women’s Health Policy were put out in 1989, and the Inquiry into the Human Rights of the Mentally Ill, in 1993. The latter two draw attention to the relevance of childhood abuse for later adult mental health issues. However, neither the First National Mental Health Strategy of 1992–1998, nor the Second National Mental Health Strategy of 1999–2003 addressed the issue of abuse. Current initiatives at national and state levels seek to promote public awareness and early intervention for depression. However, its psychosocial antecedents, such as a person’s childhood abuse, remains as yet largely unaddressed in these initiatives. National, state, and discipline-wide protocols for appropriate abuse-specific healthcare still remain, sadly, a future goal. International, as well as Australian statistics on the prevalence of past childhood sexual abuse among adults indicates the seriousness of the issue. Research has established that abused children could have significant long-term health issues. Such research has been increasingly rigorous in methodology since the 1970s with regards to definitions and criteria. Emotional, behavioural, mental and psychosomatic consequences of past childhood abuse are now acknowledged for adults. It is also clear that childhood sexual, emotional or physical abuse, as well as neglect can be equally devastating.

The current situation So what about now? Is it any easier now for survivors with long-term mental health issues to access specific help? Essentially, although practitioners are far more aware of the issue now, survivors still struggle to find appropriate help. In community health centres as well as among sole practitioners, availability of abuse-specific help to a survivor varies according to


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the policy of the agency, and interest of the individual practitioner, rather than by state-wide or discipline-specific protocols for such help. Many such agencies as well as general medical practitioners continue, in the main, to regard appropriate expertise as a ‘specialised’ field. Those primary health practitioners, who do work with survivors can struggle with complex issues such as suicidal ideation or substance-use. Referral continues for survivors to generally be a time of disjunction, because mental health, and drug and alcohol services that they have been referred to, are ill equipped to meet their abusespecific needs. Psychological therapies remain mostly unavailable for a survivor in these public sector agencies. Local medical practitioners, although financially partially viable to a survivor through Medicare, vary in their preparedness to incorporate the relevance of childhood abuse into help for emotional, psychosomatic and physical health issues of adult survivors. In any case, finding time for such intensive work in busy general practice schedules continues to be prohibitive for most doctors. The burgeoning field of complementary health, too, requires a mention. Survivors, disenchanted with Western medicine’s neglect of the mind–body axis, may seek complementary health practitioners despite the lack of Medicare rebate for such services. Interested practitioners— In summary, despite similar to their counterparts in private psychotherapy— strides in public accrue experience relevant to this particular field, and seem awareness of the open to applying it towards resolving complex mind–body issues of survivors. issue of child sexual Private psychiatrists vary in the importance they abuse, as well as place on psychological interventions in comparison with availability of research pharmacological interventions. Many place emphasis on findings regarding its treating symptoms like depression, considering abuseimpact on the adult specific work to be a separate ‘special interest’ expertise. health of survivors, In summary, despite strides in public awareness of the abuse-specific mental issue of child sexual abuse, as well as availability of research healthcare is not findings regarding its impact on the adult health of generally, or easily survivors, abuse-specific mental healthcare is not generally, available. or easily available. While adult survivors in urban areas may be able to obtain short and medium-term abuse counselling, specific long-term work that is needed for mental, psychosomatic, and psychosocial consequences of childhood abuse remains largely unavailable. In this light, what options a survivor would have for abuse-specific healthcare in regional and remote areas remains conjecture.


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Abuse-specific mental healthcare: a current snapshot Adults who have suffered childhood abuse seek help for mental health, psychosomatic, and psychosocial issues. They approach a variety of health and welfare agencies but find it extremely difficult to get abuse-specific help. n Primary health practitioners have variable expertise and time. n Disclosure of abuse can temporarily worsen symptoms. n Concerned for safety, practitioners seek to refer the survivor elsewhere. n Referral at such a time is difficult for a survivor. n GPs might focus on symptoms without addressing abuse-specific issues. n Sexual assault and domestic violence agencies are mostly able to offer only time-limited help and, also, lack mental health expertise needed for complex mental health issues. n Public sector mental health, and drug and alcohol agencies seldom undertake abusespecific work. n Survivors who have long-term mental health, psychosomatic and behavioural issues need their health practitioners to have dual expertise in mental health as well as abuse-specific work. But this is seldom available or affordable.

So what can be done? The scale of the problem and funds required to address this issue might at first sight seem daunting. However, a significant first level of abuse-specific help can be provided to survivors if public sector community health, mental health, and drug and alcohol services, to name some, were to incorporate aspects of this work. Collaboration between practitioners with complementary skills, and networking between agencies can go a long way in delivering this level of mental healthcare for survivors—if they have first level of abuse-specific expertise and an understanding of differences between frameworks. The crux of the issue is for health planners to take up this issue as a policy matter at state and national levels. Such policy needs in the first instance to endorse delivery of a first level of abuse-specific work within public sector health, and mental health services. It then needs to encourage, and make available, appropriate training for practitioners. This book is written for primary health practitioners from different training backgrounds interested to take up such a first level of abuse-specific work. In doing so, it advocates for adult survivors of childhood sexual abuse to be given a real chance to address their mental health, psychosomatic, and psychosocial needs.


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FURTHER READING Breckenridge, J & Carmody, M (eds). Crimes of Violence: Australian responses to rape and child sexual assault. Allen & Unwin, St Leonards, 1992. Bricker-Jenkins, M, Hooyman, NR & Gottlieb, N (eds). Feminist Social Work Practice in Clinical Settings. Sage Publications, Newbury Park, 1991. Briere, JN. Child Abuse Trauma. Sage Publications, Newbury Park, 1992. Briggs, F (ed.). From Victim to Offender. Allen & Unwin, St Leonards, 1995. Classen, C (ed.); Yalom, ID (general ed.). Treating Women Molested in Childhood. Jossey-Bass Library of Current Clinical Technique: Jossey-Bass Publishers, San Francisco, 1995. Finkelhor, D et al. Sourcebook on Child Sexual Abuse. Sage Publications, Newbury Park, 1986. Furniss, T. The Multi-professional Handbook of Child Sexual Abuse. Routledge, London, 1991. Herman, JL. Trauma and Recovery. Basic Books, New York, 1992. Meiselman, KC. Incest. Jossey-Bass Publishers, San Francisco, 1978. Miller, A. Breaking Down the Wall of Silence. Virago Press, London, 1992. Pearlman, LA & Saakvitne, KW. Trauma and the Therapist. WW Norton & Company, New York, 1995. Salter, A. Transforming Trauma. Sage Publications, Newbury Park, 1995. Van der Kolk, BA, McFarlane, AC & Weisaeth, L. Traumatic Stress. Guilford Press, New York, 1996. Walker, M. Surviving Secrets. Open University Press, Buckingham, 1992. Wilson, JP & Lindy, JD (eds). Countertransference in the Treatment of PTSD. Guilford Press, New York, 1994. Wyre, R & Tate, T. The Murder of Childhood. Penguin Books, London, 1995.


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136

INDEX abuse developmental, 8 seductive, 29, 40, 58 social context, 128–130 types, 15, 29, 129 see also trauma advocacy, 30, 35, 129 aftermath of abuse ill health, 12 mental health, 13, 52–6 types, 2, 11–13 see also behaviours, survivor aftermath; functioning, survivor aftermath agency framework, 20 type approached by survivor, 17–19 aims of abuse-specific work in early work, 65–6 in ongoing work, 100 ambivalence, 58, 68, 80 anger experiencing, 55 expressing, 56 anxiety symptoms of, 83 techniques to reduce, 78 assertiveness, 55–7 development of, 8, 40 assessment abuse-specific, 28–30 agency-specific, 25 holistic, 25–8 risk, 30–3 balance of empathy and objectivity, 107 of exploration and containment, 109 behaviours, survivor aftermath ambivalence, 58, 107 appeasing, 56, 107 assertiveness, 55–7 being direct, 57, 108 difficulty to confront, 56 entrenched, 101, 103 body-sense, 90 borderline personality, 95–7 boundaries, maintaining in early work, 104 in ongoing work, 112 see also misconduct, professional boundary, survivor awareness of other’s, 63


personal, 59 burnout, worker, 112 code of practice, 3, 25, 32 cognitive-behavioural, techniques, 4, 78, 79 collaboration between services, 45, 95, 105, 110 between survivor and practitioner, 73 co-morbidity, 11, 35, 36 competence, practitioner differences, 3, 38, 45, 106 gauging, 12 staying within, 5, 25, 76, 100, 119 complementary health, 133 confronting the perpetrator, 89, 116 containment techniques, 108 content of sessions in early work, 66–70 in ongoing work, 101–103 coping strategies facilitation of, 46, 73, 77 identifying customary, 26, 32 coping, survivor developmental aspects, 8, 13 entrenched methods, 15 gauging level of, 45–6 counselling, variations, 21 depression related techniques, 79 symptoms, 82 directness, survivor difficulty with, 56 disclosure first, 30, 68 to professional, 129, 132 work, 67–8, 101–102, 130 dissociation, 31, 83–5 duty of care, practitioner, 37, 45, 76, 81–2 flashbacks, 34, 85, 117 frameworks agency, 20 differences, 22, 89, 116 justice, legal, 20, 22, 116 relevance to survivor, 21, 116 services, 19–22, 116–117 sole practitioner, 20–1, 37, 117 functioning, survivor aftermath guilt and self-blame, 13, 52 intensity of need, 48, 112 secrecy, 53 self-confidence and self-esteem, 52

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INDEX

gender issues, 38 goal plans, abuse-specific, 34 options, 35 outline, 36 priorities, 34 time-plan, 35 goal plans for co-morbid health, 33, 36, 38 group work, 107, 109 guilt, 13, 52 healthcare, service settings primary, 5, 81, 131 social context of, 129–134 see also policy, healthcare healthcare, survivor co-morbid, 38, 92 holistic, 7, 38, 128 pathway in, 18, 36 Human Rights and Equal Opportunity Commission Act, The, 132 ill health, general health managing, 38 see also healthcare, survivor, co-morbid ill health, mental health managing, 101 types, 82–9 Inquiry into the Human Rights of the Mentally Ill, 132 insight, 49, 62–4, 97–9 interactions, practitioner awareness of dynamics, 49, 104 gender dynamics, 38 see also transactions, in abuse-specific work interactions, survivor dynamics, 57, 107 help-seeking, 48–9 patterns, 26, 27, 107 interactive space, safe, 63, 102 interpretations, 93, 108, 125 see also making links intimacy issues, 57–62 re-enactment of abuse, 61 legal considerations, 68, 89, 116–117 in memory-work, 120 limit-setting of behaviour external, 22, 50, 99 internal, 62, 97 see also perpetrator, denial and justification making links, 93, 102, 125 management plan, 33–6


137

see also goal plans, abuse-specific medication, 80 memory classifications and terms, 113–115 retained, 115, 118 returned, 115, 118–119 triggers, 117 memory-return complete, 118 fragmented, 119 process of, 117–119 survivor control over, 120 types of, 118–119 memory-work, 102, 119–127 mental ill health, see ill health, mental health mind-body axis, 89–93 misconduct, professional, 62, 104–105, 117 motivation, survivor, 63, 98 National Mental Health Strategy, 132 National Women’s Health Policy, 132 networks practitioner, 4, 105, 110 survivor, 27 objectives of abuse-specific work abuse-specific, 33–5 agency-specific, 33 Our Homeless Children, 132 pace of work related techniques, 109 survivor control over, 41, 102 peer support, practitioner, 109, 112 perpetrator confronting the, 86–9, 116 denial and justification, 9, 22, 50 details, 29 grooming, 9, 63 perpetrator work, differences, 22, 27, 62, 64 personality developmental aspects, 96 disorders, 95–7 traits, 13, 52, 95 pitfalls managing, 44–50 survivor-related, 48 worker-related, 50, 80, 112 policy agency, 109 healthcare, 128–132 state and national, 134 post-traumatic stress disorder, 85, 131 power issues, 52–5 developmental aspects, 9

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138

INDEX

power issues (cont.) gradient, 22, 52 perpetrator-related, 29, 39, 40 practitioner-related, 40, 62, 112 primary healthcare, 5, 81, 131 principles in abuse-specific work general, 3–4, 38–44 in early work, 66 in ongoing work, 101 privacy, 21, 49, 62 psychodynamic techniques, 4, 79 psychodynamics, of transactions awareness of, 107, 112 managing, 40 psychosocial context of abuse, 4 providing information on, 70–3 psychosomatic illness, 12, 91–3 re-enactment of abuse, 30, 61, 104 of childhood patterns, 27, 79, 101 role of secrecy in, 10 referral, 38, 109, 111 rehabilitation, 103 resilience, 27, 49, 50, 64 revolving door pattern, 18, 33, 132 risk assessment, 30–3 behaviours, 31 types, 31 risk management, 13, 42–8 gauging level, 32 monitoring, 36, 101 see also safety, in abuse-specific work safety, in abuse-specific work gauging level, 45 in early work, 74–5 in ongoing work, 101, 105 protocols, 36, 47–8 safety, survivor’s difficulty to gauge, 54 secrecy, benefit of group work, 107 secrecy, impact of, 10, 53 psychosocial context, 10, 62 self-blame, 40, 52 self-confidence and self-esteem, 52 self-harm, 12, 31, 107 see also risk, behaviours self-help groups, 129 services current spectrum, 22, 132–4 framework, 20 sexuality, 60 shame, 13, 52 social stigma, 13, 52, 53, 107


societal awareness of abuse, 62, 72–3, 128 response to abuse, 62, 129, 132 somatic signals, 91–3, 108 splitting, 57, 80, 108, 112 strategies, 4, 22 balance of, 104 for co-morbid healthcare, 101 in early work, 70–6 in ongoing work, 104–105 survivor’s preferred, 4, 35, 47 substance use, 12, 93–5 suicidal ideation, 31 see also risk, behaviours supervision for worker, 109, 112 survivor control over process, 77, 120 coping techniques, 77 intensity of need, 48, 112 pathway in healthcare, 18–19 survivor experience groundedness in, 106, 122–5 validation of, 36, 68 symptoms of co-morbid ill health, 101 understanding, 70–71 techniques, in abuse-specific work, 4 balance of, 45, 74, 109 exploratory, 106 for containment, 41, 108 survivor control over, 77 to match strategy, 109 techniques, stages in early work, 76–80 in ongoing work, 105–109 time constraints, 42, 82, 109 plan, 35 transactions, in abuse-specific work, 39 awareness of dynamics, 104 equality of, 40 principles underpinning, 39–42 safe, 66, 101 transparency of, 66, 111 trauma adult, 8 developmental, 7 intentional, 9 traumatic events coping with, 9 outcome difference, 8 types, 9 triggers day-to-day, 41, 47, 92

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INDEX

for memory-return, 117 trust issues developmental aspects, 9 in abuse-specific work, 40, 66 in survivor functioning, 58 validation of survivor experience, 36, 68 veracity of memory, 116


139

victims of crime, 131 women’s movement, 129 worker-related issues, 50 in early work, 80 in ongoing work, 111–112 World Health Organization, 128

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to the mental health of adults who were sexually abused in childhood. An increasing number of adult survivors are seeking healthcare that is specific to their childhood sexual abuse. Many practitioners feel inadequately trained to cope with such a complex issue and the availability of affordable specialists does not match the need. Specific training in such work is still not available and a general appreciation is lacking that healthcare for the adult mental health issues of survivors needs to be abuse specific.

After Abuse

A health practitioner’s guide

After Abuse sets out clearly the complex implications of childhood sexual abuse for a person’s adult mental health. It presents a model of abuse-specific help for health practitioners from different training persuasions. The book’s jargon-free language and numerous case-study examples cut across professional demarcations.

Gita Mammen is a psychiatrist and psychotherapist. She has worked in public, private and academic settings, and has been a member of the Victorian Ministerial Advisory Committees on mental health and women’s health. Gita’s work with adult survivors in individual and group psychotherapy since the 1980s informs After Abuse.

Gita Mammen

After Abuse is essential reading for primary healthcare practitioners in community health, rural health, mental health, solo private practice, and for those practitioners who have been approached by adult survivors for help with health issues related to their childhood sexual abuse.


Australian Council for Education Research

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After Abuse

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Обуза (Abuse)

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After

After

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After Abuse

Prescription Drug Abuse (Drug Abuse Prevention Library)

Обуза (Abuse)

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Ritual Abuse

Child Abuse

Drug Abuse

After

After

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After

After

After

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After

After

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Domestic Partner Abuse

Churches That Abuse

Drug Abuse Handbook

Юрий Нестеренко. Обуза (Abuse)

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Abuse of Power

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