Counseling survivors of sexual assault

My journey (Brooke Bagley) of developing a five-phase model of counseling began in 2013 as I was completing my master’s-level graduate program and transitioning into a therapy position at a local area sexual assault center where I had worked since 2010. For the past three-plus years, I have listened to horrific stories, learned to establish rapport, identified helpful strategies, empowered my clients, observed healing, prompted restoration and marveled at my clients’ resilience. All the while, I was unintentionally and unknowingly developing an effective counseling model.

During the past two years, I’ve also been receiving supervision toward licensure from Joel Diambra, the secondary author of this article. I discovered (or uncovered) “my” model of counseling when he recognized that I had a sequential pattern to my counseling and asked me to begin identifying what I was doing and the reasons I was doing it. Thus, I began to reflect on my counseling practice and, over the course of several weekly licensure supervision meetings, we crafted a five-phase model — my way of counseling survivors of sexual assault toward healing and restoration.

Just the thought of counseling someone who has been sexually assaulted may be daunting for many counselors. I think it’s fairly natural for most counselors to feel professionally inadequate when they knowingly encounter their first client who has been sexually assaulted. Although my five-phase model is based in foundational counseling theories and skills, I offer it here as one guide for counseling clients who have experienced sexual assault. Perhaps it will provide a road map for other counselors serving similar clients.

 

Phase 1: Assessment and education 

Phase 1 primarily consists of effective assessment skills, identification of presenting problems and initiating the first steps toward building rapport and developing language (matching age-appropriate terms, paralleling word usage, avoiding trigger words, etc.) that is most effective for the client. The amount of time spent in this phase typically ranges from one to three sessions depending on the client’s trauma history, presentation and comfort with therapy, and assessment of the client’s basic needs.

During this phase, it is imperative for counselors to maintain a high level of empathy to create an environment of acceptance and comfort. Many survivors of sexual assault struggle with feelings of shame, guilt, embarrassment and defectiveness, and have a decreased level of trust in others who are outside their identified support systems. To facilitate an environment that feels supportive and safe, I use the client’s own language, focus on appropriate and accurate reflections, and allow the client to emote without much intervention on my part.

The psychosocial assessment covers basic client-related information familiar to most mental health providers. This assessment provides insights regarding a client’s familial, medical and work-related history, in addition to current issues and past functionality. I complete the assessment to focus more on trauma-related history, both specific to sexual trauma and complex trauma (any previous trauma-related incidences a client identifies as having experienced). This focus is helpful in gauging client resilience, gaining insight into a client’s threshold for stress and obtaining increased awareness of potential maladaptive cognitive patterns the client might possess related to any current situations or traumas. At this point, the initial narrative (the client’s first retelling of the traumatic experience) is established, and I am able to incorporate the client’s language into future interactions to help in developing rapport and trust.

Phase 1 also consists of a psychoeducational focus that is helpful in increasing the client’s confidence in pursuing and maintaining therapy services. After completing the psychosocial assessment, I file the assessment in the client’s chart to review later in the therapeutic process and provide the client with trauma-related materials on normative responses that may be experienced in all facets of the client’s functioning (cognitive, emotional, physical, mental, social, etc.) At this time, I walk the client through a trauma symptoms checklist that includes emotion-, behavior- and cognitive-related questions. These questions and the corresponding answers offer insights into the client’s level of affectedness, while simultaneously educating the client on how and why certain symptoms have manifested.

Phase 2: Rapport and strengths

Building rapport and identifying strengths are major components of allowing successful trauma processing and resolution to occur. In phase 2, I encourage clients to take a break from our immediate focus on the sexual trauma and to instead explore their perceived strengths. This action facilitates the instillation of hope. This phase deviates slightly from other trauma-focused therapies by offering clients allotted time to engage in intrapersonal exploration that is separate from their trauma. This approach is geared toward a focus on what they still have versus what they feel they have lost.

Rapport building starts with intentional focus on empathy versus sympathy and the utilization of unconditional positive regard. This is accomplished by allowing clients to clarify their self-perceptions, identify as “survivors” or “victims,” and so on. This is the perfect time to incorporate the language or narrative the therapist has picked up from clients in the initial sessions. This conveys to clients that they were heard and listened to and, thus, are being cared for. I often explain the difference between empathy and sympathy during this phase to help clients identify which felt most supportive and when. This is also helpful to clients outside the counseling office because they are better able to identify those in their lives who provide this level of support and others who are less able to support them.

During the second phase, survivors of sexual abuse often report a reduced perception of control, diminished trust in others, a negative view of self and decreased feelings of worth related to being loved, cared for and valued. In this phase, I encourage clients toward increased positive views of self and self-confidence and the ability to seek support from individuals who can provide it. This skillset and a more positive perception of self are helpful over the course of the therapeutic journey.

Additionally, I explore clients’ past coping successes — activities they have previously engaged in that have been helpful in decreasing general stress — and work with clients towards creating a coping skills “kit” for emergency access. This provides go-to coping strategies when future trauma-related escalation occurs. When packing their kits, clients have included such items as adult coloring books, chocolate, scented oils, music playlists, the contact information of support people and so on.

Phase 3: Cognitive intervention

In phase 3, I explore clients’ cognitive processing. We work to identify thought patterns that lead to self-deprecating perceptions and triggering responses. I often alternate between the cognitive distortions focus of cognitive behavior therapy (CBT) and the emotion-incorporated theory of rational emotive behavior therapy (REBT).

During this phase, I recall the initial assessment (initial narrative of recent trauma) and work with clients to identify how they retell their history and describe their current functioning. Using a predeveloped checklist of common cognitive distortions, I work with clients in session to identify which distortions they are experiencing. Once clients are aware of these patterns, I encourage ongoing mindfulness activities to increase recognition of these cognitive distortions outside of therapy.

For example, I often give homework in the form of thought logs to help clients record triggering events, thought responses and actions taken. For clients who are less engaged in homework, a simple rubber band on the wrist is used to help clients heighten and maintain awareness. They do this by snapping the rubber band every time they experience a trigger. The hope is that if they find themselves snapping recurrently, they will in turn pay more attention to their maladaptive thoughts and can then better self-identify and later verbalize these patterns in therapy. Some of the cognitive distortions that clients commonly report to me include: “I am damaged”; “I will never be the same”; “I should have done something different”; “Nothing good ever happens to me.”

Once we identify negative thought patterns and triggers, we begin working toward positive and realistic reframes while continuing to focus on coping skills from the previous phase. I encourage clients to share their perceptions of their situations and, together, we begin to break down these thought patterns to help them process their experiences differently. For instance, a client might state, “My family seems uncomfortable when I bring up my assault. They must think I am overreacting.” In this case, we would work to create a healthier, more adaptive reframe such as, “My family may appear uncomfortable when I bring up my assault, but maybe it is because they are not sure how best to support me.”

This provides a reevaluation of the client’s perception. The hope is that clients will then recognize the potential in their support systems and, incorporating increased self-confidence from the previous phase, will feel comfortable conveying and eliciting more effective and efficient support from friends and family members.

Phase 4: Emotion focused

Phase 4 is primarily focused on emotion-based responses and interventions, along with the incorporation of mindfulness. I purposefully separate this from and have it follow the cognitive phase because I have found there are residual and intense emotional responses that often outweigh clients’ abilities to rationalize or self-soothe. Clients with complex trauma or a lack of effective coping skills often report numbness, a sense of disconnect from their bodies, intense and seemingly uncontrollable anxiety responses, and self-harming or self-medicating behaviors in various forms. In this phase, I primarily use Gestalt-based interventions to help clients better understand mind-body communication as it relates to emotional response.

The Gestalt interventions I use with clients are primarily focused on bodily sensations and reexperiencing physiological reactions. For this focus, I teach and encourage clients to practice body scanning on a regular basis but especially when experiencing more intense emotional reactions. The purpose is to have clients become better acquainted with specific aspects of their emotional functioning and the associated feelings linked to their bodies. This intervention allows in-the-moment understanding of how certain emotions manifest physiologically and encourages an increased awareness of clients’ specific responses to emotions in triggering conditions.

I ask clients to walk me through a recent trauma-related episode, having them focus on what they felt bodily versus emotionally or cognitively. Many clients report feeling like anxiety manifests in their digestive tract (stomach, bowels) in the form of cramps and intense aching or, alternatively, in the form of pressure in the temples of the head or behind the eyes.

Some clients will report a complete disconnect when they experience intense emotional reactions. They become physically numb and feel no sensation — much like physical denial. Clients who disconnect are more prone to self-harm. They tend to revisit this unhealthy form of coping even if it has not been in active state for them for some time.

A common practice I use for working with this trauma response is based in mindfulness. I encourage clients to engage all five of their physiological senses by directing them to pick different therapeutic items up in my office (essential oils, stones, stuffed animals, mints, wall art, etc.) to smell, touch, taste, listen to and focus on visually. Once this senses-based intervention has been practiced within the therapeutic office, I encourage clients to continue using this intervention at home. A more severe tactic of grasping ice has been found to be helpful for clients who have tendencies toward self-harm. The ice allows for a physiological stimuli or shock to the body that engages sensation centers in the brain similar to those engaged in cutting, burning, etc. The hope is that these clients will choose items that are pleasing to them over items that are unpleasant, thus creating more positive experiences that involve bodily sensations.

Phase 5: Trauma narrative

The final phase in this model is focused on the trauma narrative. It is at this point in the therapeutic process that clients are displaying and self-reporting more stable emotional and cognitive-related responses to stress and more effective use of healthy coping skills.

I encourage survivors of sexual assault to begin writing out their trauma narratives, which occurs in session. Retelling their stories has been empirically proved to decrease the severity of the trauma response. It also allows clients to apply new meaning to their experiences and incorporate new and positive self-views and language. I do not recommend writing trauma narratives outside of the therapy session, however, because clients with a recent trauma can still be easily triggered. This is especially true when the narrative directly engages their previous trauma.

Once an initial narrative is written, I have the client read it out loud two separate times within the same session, or sometimes over the course of two sessions depending on the client’s responses to the narrative work. The first time, clients read their accounts of their trauma verbatim. From there, we are able to explore and process their reactions to the narrative and gauge their level of trauma response. I then ask clients to reread their narratives in the third person, as though they are telling someone else’s story. This allows them to take a bird’s-eye view of their trauma experience and perceive it differently, which often results in clients permitting more empathy and understanding for themselves.

Implications and model tenets 

My experience with this model in treating survivors of sexual assault has been favorable. Using this five-phase model, I have maintained a high client retention rate of 70 percent and a low cancellation rate of approximately 25 percent (compared with a typical rate of 40 percent within our center) over the past 18 months. Most clients report an overall increase in functionality after three sessions. These same clients have engaged in trauma work sooner in the therapeutic process than have our clients treated without the five-phase model.

Tenets of this model include effective assessment skills, a focus on client history and complex trauma, empowerment and encouragement of clients, an empathic strength-based approach and the incorporation of CBT/REBT and Gestalt-based interventions.

 

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Brooke Bagley, a national certified counselor, is a therapy team leader/supervisor and clinical mental health therapist at the Sexual Assault Center of East Tennessee. Contact her at brookelynnbagley@gmail.com.

Joel Diambra is an associate professor of counselor education, associate department head and director of graduate studies in the Educational Psychology and Counseling Department in the College of Education, Health and Human Services at the University of Tennessee in Knoxville. He is a licensed professional counselor-mental health service provider. Contact him at jdiambra@utk.edu.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.