Working with adult survivors of child sexual assault
Like adult victims, children experience significant psychological and emotional distress. Unlike adults, however, they are traumatized during the most critical period of their lives:
- When assumptions about self, others and the world are being formed;
- When their relations to their own internal states are being established; and
- When coping and relationship skills are first acquired.
Therefore, the Post Traumatic Stress reactions impact upon the child's subsequent psychological and social maturation leading to atypical and potentially dysfunctional development. In other words, if untreated, the effects of sexual abuse in childhood are usually more dynamic and interactive, in contrast to trauma effects in adults who have a stable base development and maturation to draw on and for whom, with support, the trauma effects will wane over time.
Impacts of childhood sexual abuse are likely to occur in three stages.
- Initial reactions to victimisation:
- involving Post Traumatic Stress reactions;
- alteration in normal childhood development;
- painful affect; and
- cognitive distortions.
- Accommodation to ongoing abuse:
- involving coping behaviours intended to increase safety and/or decrease pain during victimisation (i.e. memory suppression, denial, dissociation, accommodation syndrome; Stockholm syndrome).
- Long term elaboration & secondary accommodation reflecting:
- the impacts of initial reactions and abuse-related accommodations on the individual's later psycho social development; and
- the survivor's ongoing coping responses to abuse related dysphoria. (Cognitive distortions, denial, memory suppression, dissociation, altered emotionality, impaired self-reference, avoidance, disturbed relatedness).
For adults abused in childhood, who received no counselling or support at the time, some of the initial reactions of victim's to the abuse may abate over time but more typically such disturbances along with abuse-specific coping behaviours, generalise and elaborate over time. The typology by Finkelhor and Browne taken together with PTSD adequately describes these core impacts and their psycho-social and behavioural sequelae. These are the impacts which need to be addressed in working with adult survivors of childhood sexual abuse.
The key objective of counselling intervention with adult survivors of childhood sexual assault is to facilitate trauma resolution and foster healing and growth.
Normalisation of the survivors reactions to the abuse experience and the effects this has had on their psychological functioning, both historically and currently, is a key factor. It's important to point out that the coping strategies they evolved allowed them to survive at the time and adapt to their experiencing. In that way, these strategies served them well. However, these responses have become maladaptive in adulthood and limit their ability to live a full life, limit their interpersonal relationships and their psychological functioning.
Education of the adult survivor about the prevalence and later psychological effects of childhood sexual assault is also important. It helps destigmatise their own experiencing and also serves to normalise their responses. Information about the lasting effects of childhood sexual assault, the types of difficulties experienced and presenting symptoms survivors encounter and how to cope is readily available and helps the survivor better understand their own range of behaviour or responses. There is a lot of information of this type available in the form of books, journal articles, and videos.
Both normalisation and education are critical particularly at the beginning of the counselling process and can be seen as preparing the survivor for the healing process. Once the survivor has entered counselling it is also imperative as part of this preparation to clarify what he or she can expect as they work on their abuse issues. The counsellor needs to be honest in informing the survivor that the healing process will not be easy and that their memory of the abuse will not magically go away. Be very clear about what you can do as a counsellor and what the survivor may expect as an outcome of their healing process.
What we can do as counsellors is provide a safe environment and a structured process within which to help survivors acknowledge their memories and associated pain, assess the influence these have on their behavioural repertoire and begin to integrate them with his or her adult self. This integration will allow the survivor to process the memories and pain so that they no longer control their behaviour and responses. He or she will be able to take control of his or her own life rather than continue to be controlled by maladaptive behaviour patterns and responses as if they and their abuse experience are 'frozen in time'.
Treatment phases and structuring the healing process
The early phase of therapy with adult survivors of childhood sexual abuse focuses on building up trust between the counsellor and the survivor and preparing the survivor for the healing process. During this phase of therapy the survivor is encouraged to tell their story which allows the counsellor to assess which therapeutic techniques may be the most beneficial.
Telling their story is difficult for some survivors. Their memories are fragmented and all jumbled up making it hard for them to relate what happened when. There is often a feeling of being overwhelmed by the abuse and just not knowing how to start. Many survivors just can't differentiate between episodes of abuse and their whole sense of childhood was taken over by it. At this stage there are tools which can be used to help the survivor put their childhood back together into a recognisable whole by focusing on specific incidents or episodes of their lives to structure their stories.
The middle phase of therapy is where the brunt of the work is done which includes re-processing the trauma. Simply stated, processing the trauma of childhood sexual assault involves:
- Acknowledging the fact of the abuse and its impacts.
- Experiencing and releasing some of the feelings associated with the trauma that typically has remained unexpressed.
- Exploring a range of feelings towards the abuser/s and non-protective parents, siblings or caretakers; and
- Making cognitive reassessments of the abuse (i.e. why it happened, who was responsible etc).
If these avenues are explored, the traumatic events are faced and processed by necessity. The abuse can no longer remain frozen in time and continue to maintain the survivors status quo: The status quo that includes beliefs about vulnerability, helplessness, mistrust, stigmatisation, with a negative view of self and others. During this phase the abused child is integrated with the adult self so that they work together as a unified whole rather than being split and working against each other. Emphasis is also placed on cognitive restructuring, educating the survivor and the formulation of new coping strategies. Through this sort of trauma processing a clear line is drawn between the past and the present leaving the individual feeling more in control and determined to deal with the impacts the abuse has had on their lives.
It is at this stage that a stronger sense of self and changes in world view evolve and new coping skills can be incorporated into their behavioural repertoire. At this stage the survivor actively engages in healing making decisions about the options open to them. This is also a stage of exploration of possibilities which can lead the survivor further along the path to integration. This is a good time for group work, self-esteem and assertiveness training, stress management and/or self-defence classes.
The last phase of the healing process is the termination phase. This involves empowering the survivor to make their own choices and decisions without relying on the counsellor. It includes the survivor's separation from the counselling process while establishing support networks. These might include self-help support groups as well as supportive friends, partners, or family members.
Treatment of adult survivors of childhood sexual assault incorporates a number of therapeutic approaches which reflect major the theoretical schools of therapy, emotional, cognitive and behavioural. Experiential or exploratory techniques focus on accessing emotions, re-experiencing the trauma and integrating these with the adult self. Cognitive therapy aims to identify the survivor's distorted cognitions of themselves, others and the world and attempts to replace these with more accurate and realistic cognitions. Behavioural therapies focus on enhancing the survivor's behavioural repertoire through the acquisition of more adaptive behavioural responses, coping strategies and learning new skills.