Tag Archives: sexual abuse

Counseling survivors of sexual violence

By Amy E. Duffy November 4, 2019

After spending more than 14 years in the mental health field working with a variety of populations, including gang-affiliated youth, adults with chronic and persistent mental illnesses, combat veterans, and survivors of human trafficking, I am struck with an inescapable theme: Sexual violence plagues every facet of society. Sexual violence does not discriminate, regardless of demographics.

As a counselor, I entered this field to become a helper and to become a part of something bigger than myself. Fred Rogers could not have said it any better: “Look for the helpers. You will always find people who are helping.” This sentiment still rings true in my heart, but one thing the mental health field has shown me is that helping sometimes requires us to combat the systemic and institutionalized injustices that are prevalent in our society.

I recently found myself in a counseling session with a college-age cisgender female who was displaying feelings of hopelessness, crying profusely, and asking me “Why?” She was directly asking me why — after her sexual assault and after exercising every legal right available to her — the system was failing her. I was apologetic for her experience, but I found myself at a loss for words. She was correct; the system was failing her. Our society and our legal system have justice gaps that are expansive. I couldn’t think of an answer I could provide in that moment that would address her feelings of hopelessness.

In subsequent months, as I became aware of similar scenarios playing out with other clients, I began to feel both compassion fatigue and burnout begin to take root. As I’ve mentioned, my intention as a counselor is to help, and I felt that I was not helping enough. I know trauma and its associated treatment modalities like the back of my hand, but that didn’t mean I was doing my part to address the gaps in justice or systemic and institutionalized inequalities that were drastically affecting my clients and their shared experience with sexual violence.

Professional counselors cannot ignore the reality that 1 in 3 women and 1 in 6 men report some form of sexual violence over the course of their lifetimes (according to the National Intimate Partner and Sexual Violence Survey 2010-2012 state report). The Thomson Reuters Foundation conducted a survey in 2018 that concluded that the United States was the 10th most dangerous country for women among the 193 member states of the United Nations; it tied for third among nations where women were most at risk for sexual violence. The foundation defined sexual violence as “rape as a weapon of war; domestic rape; rape by a stranger; the lack of access to justice in rape cases; sexual harassment; and coercion into sex as a form of corruption.” Unfortunately, I have personally borne witness to each of these definitions of sexual violence while working in the mental health and counseling fields.

Given the epidemic of sexual violence, both domestically and globally, it is impossible for counselors to avoid contact with individuals who have survived such violence. To date, counselor education programs do not have a reputation for providing an adequate and thorough understanding of practices for working with this population in their curricula. In addition, progress in the field of sexual violence has been negligible, partially due to the significant gaps in research necessary to better inform prevention, policy and advocacy efforts. These absences of vital counseling resources triggered my desire to explore the Multicultural and Social Justice Counseling Competencies (MSJCC) in search of a plausible answer to this dilemma.

The MSJCC

The MSJCC, developed by Manivong Ratts, Anneliese Singh, Sylvia Nassar-McMillan, S. Kent Butler, and Julian Rafferty McCullough, recognize that individuals are part of a larger ecosystem in which privilege and marginalization coexist. The MSJCC provide a framework to best support survivors of sexual violence not simply on the intrapersonal level, as addressed within treatment models and counseling strategies, but on all socio-ecological levels, through advocacy and action. The MSJCC emphasize the importance of understanding individuals in the context of their social environment while advocating for social justice within that social environment.

In addition, the MSJCC framework acknowledges the need for understanding the complexities of diversity and multiculturalism within the counseling relationship, as well as recognizing the negative influence of oppression on mental health and overall well-being. This framework reinforces the need for counselors to recognize and uphold the reality of intersectionality, in which the various social constructs of race, ethnicity, gender, sexual orientation, economic status, religion, spirituality and disability contribute to a client’s unique worldview, experience and existence as a human being.

When counselors partner with survivors of sexual violence, both the counselor and the client need to recognize the roles that privilege and marginalization play in sexual violence and within the counseling relationship. Effective treatment and long-term healing cannot exist without this mutual understanding. The reality is that victim-blaming, rape myths and gender inequality are persistent elements in American culture and globally; these cultural characteristics constitute what is known as rape culture. Victim-blaming is the extent to which society holds victims of sexual violence responsible for their own victimization, whereas rape myths are stereotyped false beliefs regarding rape, survivors and perpetrators.

Within rape culture, the survivor is marginalized while the perpetrator is privileged, most commonly due to gender. The privilege of gender is then further extended and embedded into society within systems and institutions that protect the perpetrator. These systems and institutions are built upon the foundations of victim-blaming, rape myths, and gender inequality. For example, states such as North Carolina still have laws that blame the victim and support rape myths. These laws include the inability of a person to withdraw their consent to engage in sexual intercourse once consent has been provided. In addition, a person who voluntarily consumes alcohol and then is sexually assaulted is not protected under North Carolina criminal law because of the fact that they voluntarily incapacitated themselves.

Sexual violence is a gender-based violent act. Approximately 91% of sexual violence survivors are women, whereas roughly 9% are men (according to U.S. Department of Justice statistics on rape and sexual assault for 1992-2000). Each of these individuals has been violated in a perpetrator’s effort to oppress and exert power over the survivor. Within the counseling relationship, the counselor and client need to explore the perceived and actual characteristics of their respective marginalized and privileged statuses relative to the issue of sexual violence and in the full context of the intersectionalities described earlier.

Although toxic masculinity may be a newer term in our culture, the constructs associated with it have historically been interwoven into American culture and should be taken into account when applying the MSJCC framework with survivors of sexual violence. Toxic masculinity describes the rigid characteristics and attitudes that are often (falsely) associated with what it means to “be a man.” These characteristics include strength, violence, sex, power, and an absence of emotion and vulnerability. Toxic masculinity perpetuates sexual violence directed not only toward women but also toward men. Understanding the gender-based nature of sexual violence and social constructs such as toxic masculinity, it is vital for counselors to fully embrace the MSJCC framework and the ways in which it relates to survivors of sexual violence.

In my clinical opinion, a counselor should not enter the counseling relationship without fully understanding and accepting the reality that in American culture, 25% to 35% of people endorse rape myth acceptance and therefore engage in victim-blaming and the perpetuation of gender inequality. Counselors should also understand and accept that toxic masculinity is, in fact, a deficit for all genders. This understanding and acceptance is a component of counselor self-awareness within the MSJCC framework. Counselors must become aware of their own attitudes, beliefs and biases pertaining to sexual violence prior to engaging in a counseling relationship with survivors of sexual violence.

The MSJCC require ongoing self-awareness and personal reflection regarding the beliefs, values and biases possessed by the counselor. This is particularly important when working with survivors of sexual violence because of the socialized cultural beliefs to which all counselors have been exposed. If counselors have not adequately addressed their potential beliefs, values and biases, it can result in bolstering shame among survivors of sexual violence.

Expanding the role of the counselor

A primary concept of the MSJCC is the expansion of the counselor’s role. This expanded role is essential when working with survivors of sexual violence. Traditionally, the counseling process has occurred within the confines of an office setting and on the proverbial therapy couch. That scenario has never been adequate when addressing the needs of those who have experienced sexual violence and thus is long overdue for modification. With the inception of the MSJCC, counselors have a framework for expanding on their traditional role to provide best practices in the presence of a profound gap in justice for their clients. 

Social justice advocacy conducted within the MSJCC framework allows counselors to work at the intrapersonal, interpersonal, institutional, community, public policy, and international/global levels to address the systemic obstacles affecting survivors of sexual violence. In the remainder of this article, I will provide a hypothetical case conceptualization (representing a composite of numerous actual cases) to illustrate this multilayered application of the MSJCC framework by a counselor working with a survivor of sexual violence.

Counselor self-awareness: Beliefs, values, biases

The counselor identifies as Christian, is supportive of homosexuality and same-sex marriage, and opposes marital rape, recognizing that nonconsensual sex within a marriage is, in fact, rape. The counselor recognizes the value in people waiting until marriage to engage in sexual intercourse but believes that imposing this standard on others can inadvertently create significant pressure and shame, particularly if someone is then exposed to sexual violence. The counselor believes sexual intercourse should be between consenting persons who provide affirmative consent (with affirmative consent being defined as the presence of yes means yes rather than simply no means no).

The counselor also believes there is no place for aggression or violence within sexual intercourse. The counselor attributes this aggressive mindset in part to the prevalence of pornography, in which close to 90% of sexual acts include aggression against women (according to the 2010 article “Aggression and Sexual Behavior in Best-Selling Pornography Videos: A Content Analysis Update,” published in the journal Violence Against Women). The counselor believes that sexual violence is about power, control and dominance rather than a perpetrator’s elevated drive for sex or inability to control temptation, and that the latter beliefs reinforce rape myths and victim-blaming. The counselor also recognizes and opposes gender inequality in all spheres of life, including the sexual double standard that exists between men and women. The counselor has had consenting partners throughout her life span and has survived sexual violence twice.

The counselor has explored the antecedents to rape culture to identify her own experiences with these antecedents as well as with associated beliefs, values and biases. The counselor is opposed to traditional gender roles and finds them to be oppressive for all genders. The counselor believes that gender and gender roles should be fluid and not rigid and attributes this belief to being raised in a home where traditional gender roles were not always strictly enforced.

Regarding adversarial sexual beliefs and hostility toward women, the counselor recognizes her personal history of strained relationships with prominent female figures as a child, as well as significant “girl drama” during pre-adolescent and adolescent development. Historically, the counselor has interacted better with males and has had periods of doubting women. Regarding the acceptance of interpersonal violence, the counselor believes in standing up for one’s self, even if that means taking physical action. The counselor supports the Second Amendment but believes gun control is not adequate at this time. The counselor has historically enjoyed action movies but has recently begun exploring violence in the media.

To further understand how the counselor’s beliefs, values and biases could affect the counseling relationship when working with survivors of sexual violence, the counselor completed the Illinois Rape Myth Acceptance Scale (IRMA) and scored a 108 out of 110, indicating greater rejection of rape myths. The counselor also recognizes that this score is not reflective of the counselor’s lifelong involvement with rape myth acceptance and is aware of historically faulty thinking as an adolescent and young adult. The counselor acknowledges that self-reflection and development have contributed to her current IRMA score.

Privilege, marginalization and intersectionality

The counselor also examines the ways in which privilege and marginalization interact within the counseling relationship. The counselor is privileged due to being white, middle class, heterosexual and Christian, and having had the opportunity to obtain a higher level of education, whereas the counselor is marginalized for being a woman.

The client in this case conceptualization is privileged due to being heterosexual and Christian, whereas the client is marginalized for being a black woman of lower socioeconomic means who has not been afforded the opportunity to complete her education to date.

The counselor identifies the MSJCC quadrant of privileged counselor-marginalized client as the most appropriate to describe the counseling relationship. The counselor is also aware, however, that this is the counselor’s own perception of privilege and marginalization within the counseling relationship and that the client may have a different perception.

The socio-ecological model

The counselor begins at the intrapersonal level by sharing her worldview (as previously described) and bearing witness to the client’s worldview. The beliefs, values and biases of both parties are explored. Intersectionality is a main component within the intrapersonal level, with the social constructs of race, ethnicity, gender, sexual orientation, economic status, religion, spirituality and disability being explored by both the counselor and the client.

The counselor and the client also have an open discussion about privilege and marginalization, including the ways that they may enrich or create obstacles within the counseling relationship. For instance, both the counselor and the client have a shared experience and openly process their experiences of gender inequality and being discriminated against for being women. At the same time, the counselor openly recognizes the existence of white privilege and verbally acknowledges that her race has not made her life more difficult. The counselor also honors the specific incidences of racism that the client has experienced and is openly willing to share with the counselor.

At the intrapersonal level, the counselor and the client also discuss and process the client’s experiences with self-blame, victim-blaming, and rape myth acceptance. The client shares self-blaming beliefs such as, “I should not have gone out that night” and “I never should have had those drinks.” The client also shares victim-blaming attitudes that others have projected onto her, including how the client’s clothing was too revealing and how she could have been more assertive in her denial to engage in sexual intercourse.

Following the exploration at the intrapersonal level, the counselor begins to support the client at the interpersonal, institutional, community, public policy and international/global levels. At the interpersonal level, the counselor assists the client in exploring her various relationships and identifying a healthy social support network consisting of family, friends, neighbors and co-workers. During this time, the counselor also assists the client in implementing appropriate boundaries within those relationships that have been identified as being unhealthy or unsupportive. The client determines that several familial relationships are unsupportive due to significant victim-blaming attitudes and the demonstration of rape myth acceptance. The client then gives the counselor permission to provide psychoeducation regarding victim-blaming and rape myth acceptance to these family members and to challenge their beliefs that are further victimizing the client.

The family members resist the psychoeducation and continue to engage in victim-blaming and rape myth acceptance. Therefore, the client decides to implement boundaries to appropriately distance herself from these relationships. The client then makes an intentional effort to widen her social network by connecting with other friends and family members. After visiting a shared interest group with the counselor, the client decides to join the group in hopes of also making new friends.

At the institutional level, the counselor and the client begin to explore the social institutions with which the client is associated. During a session, the client shares that she has observed sexual harassment in her workplace and expresses concern that she will continue to be exposed to these interactions. With the client’s permission, the counselor reaches out to the employer and offers to provide an organizational training to the entire staff on sexual harassment and gender inequality in the workplace.

The client also shares that she has been a member of her church for more than a decade. She is finding it increasingly difficult to attend regularly, however, because of the feelings of shame associated with the church’s message regarding purity. The client also shares her perception that the church displays rape myth acceptance frequently during its teachings. With the client’s permission, the counselor reaches out to explore the possibility of meeting with church leaders about their own rape myth acceptance tendencies and to develop a plan with church leaders to provide a more supportive environment for survivors of sexual violence. Furthermore, the counselor uses this experience to develop a program to help all community churches create safe places for survivors of sexual violence.

The counselor’s work does not stop here. As an active member of the community, the counselor has various opportunities to address norms at the community level. For instance, when processing at the intrapersonal level, the client shared her experience with racism, disclosing that she often felt unheard during her school years and was frequently passed over when her hand was raised to contribute to class discussions. Instead, she received discipline referrals for speaking out of turn and being disruptive. The counselor validates the client’s experience with microaggressions and acknowledges this display of racism. The counselor then assists the client in connecting with a community volunteer opportunity in which the client will be tutoring school-age minority females. This gives the client an opportunity to empower not only herself but minority female youth as well.

The counselor also notices that the community has limited events to raise awareness about sexual violence, suggesting that the topic is unimportant, taboo, or not considered to be an issue within the community. With that in mind, the counselor decides to organize a committee of other counselors to coordinate an annual Take Back the Night event. The hope is to engage the community more on the topic and to create a new community norm of open discussion regarding sexual violence.

The public policy level is most closely associated with the gap in justice witnessed by survivors of sexual violence. For that reason, the counselor is intentional about making action at this level a priority. The counselor becomes knowledgeable about state and federal laws that affect survivors of sexual violence and openly shares this information with the client. The counselor attends public forums on the topic and provides expert testimony regarding the need for improved laws that protect survivors. The counselor also meets with state legislators to discuss how laws that reinforce victim-blaming and rape myth acceptance affect survivors of sexual violence and the communities in which they live.

At times, the counselor challenges the language used in sexual violence legal cases, including questions such as “What actions did you take to prevent the alleged sexual assault?” and statements such as “The victim chose to stay.” The counselor does this by reframing these retraumatizing questions and statements to be trauma-informed. In these instances, the counselor reinforces the truth that survivors cannot prevent their sexual assault from happening, nor does one’s decision to be in a specific environment suggest that survivors are responsible for being assaulted.

Similar to the public policy level, the international/global level requires the counselor to take action outside of the office and, at times, behind the scenes. The counselor educates herself on gender inequality on a global level, including human trafficking, farming disparities between men and women, unequal labor wages, lack of education for females, immigration, and child marriage. The counselor joins organizations that address these various topics, which have both direct and indirect associations with sexual violence. The counselor then disperses information on these topics on a blog linked to her website. Finally, the counselor participates in specialized training to complete immigration assessments for those seeking asylum in the United States and those hoping to gain access to their afforded protections under the Violence Against Women Act.

Conclusion

Sexual violence is epidemic in contemporary society. This epidemic is largely fostered by the prevailing rape culture in the United States and worldwide. Thus, it is highly likely that counselors will encounter survivors throughout their careers across a wide range of clientele. This article provides relevant background information on sexual violence and victimization, along with an application of the MSJCC, to promote a deeper understanding of sexual violence and to detail a promising framework for counseling and advocating for these survivors.

 

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Amy E. Duffy is a licensed professional counselor supervisor specializing in trauma and working in private practice in Raleigh, North Carolina. She is currently pursuing her doctoral degree at North Carolina State University, where she is studying gender inequality and sexual violence in her dissertation research. Contact her at amyeduffylpc@gmail.com or HarborBehavioralHealth.com.

Letters to the editor:  ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.

Addressing intimate partner violence with clients

By Bethany Bray June 24, 2019

Licensed mental health counselor Ryan G. Carlson had just earned his master’s degree when he began working on a grant-funded project to provide relationship education to couples in the Orlando, Florida, area. Overseeing the intake process as local couples came into the university-based research center to participate, he quickly learned two things: Domestic violence “is very prevalent — much more prevalent than I realized — and it’s complicated,” says Carlson, an associate professor of counselor education at the University of South Carolina. “Every case was a little bit different than the next.”

The National Coalition Against Domestic Violence reports that on average, nearly 20 people per minute are physically abused by an intimate partner in the United States. On a typical day, domestic violence hotlines across the country receive more than 20,000 phone calls.

Approximately 1 in 4 adult women and 1 in 7 adult men report having experienced severe physical violence from an intimate partner in their lifetime, according to the U.S. Centers for Disease Control and Prevention. In addition, 16% of women and 7% of men have experienced sexual violence from an intimate partner.

Carlson’s experience led him to study domestic violence while earning his doctorate, and it remains a career focus for him as he conducts research, does interdisciplinary work and conducts trainings for mental health professionals. “We assume when there’s violence in a couple’s relationship, they will tell us [in counseling]. What I’ve learned is if we don’t ask the right questions, they won’t tell us, and you shouldn’t ask those questions if you’re not ready for their disclosure,” he says. “It’s really complicated and emotionally charged. … A victim’s safety should be at the center of every decision we make as counselors.”

Handle with care

Counselors who notice patterns of maladaptive behavior, self-esteem issues or what appears to be poor decision-making by clients may automatically want to roll up their sleeves and dive into goal-setting and other go-to techniques to foster change and growth. However, engaging in change-focused work when a client is experiencing IPV may be harmful, warns Taylor Cameron, a licensed professional counselor (LPC) and director of transitional housing at Denton County Friends of the Family, a nonprofit agency in Texas that provides support services to victims of domestic violence and sexual assault. It also offers an intervention program for offenders.

The tried-and-true counseling method of talking through clients’ life scenarios, behaviors and choices while asking questions such as “What could you have done differently?” or “What would you want to change if this happens again?” can be hurtful because a counselor may inadvertently be placing the responsibility for the abuse on the victim instead of on the abuser, Cameron says. She cautions that counselors must choose their language carefully to avoid making the client feel that they are somehow to blame for the abuse they have endured.

“Victims of domestic violence do many things to survive or to try to protect themselves within the relationship,” says Cameron, an American Counseling Association member. “However, the partner carrying out the abuse is solely responsible for the violence.” Ultimately, the client can’t control — and should never be made to feel that they shoulder the blame for — what their partner does, she emphasizes.

Carlson, who is also a member of ACA, agrees. He notes that it isn’t helpful for professional clinical counselors to identify client behaviors that could be changed or avoided when clients may have adopted those patterns as a means of self-protection.

“It’s important to be careful about how we phrase things with [these] clients,” says Carlson, director of the Consortium for Family Strengthening Research and coordinator of the Center for Community Counseling at the University of South Carolina. “Avoid anything that has to do with ‘what could you have done differently?’ questions, anything that would allude to how [the client] contributed to their current situation. … It’s a delicate balance, but it’s really important to avoid language that [even inadvertently suggests] a victim is somehow at fault for being in that relationship.”

“It doesn’t matter what they change about themselves because that is not going to change the other person,” says Margaret Bassett, an LPC and deputy director at the Institute on Domestic Violence & Sexual Assault at the University of Texas at Austin. Counselor practitioners must consider the entire context of a client’s behavior to fully understand why they’re making those decisions, she says. Decisions that victims of abuse make — often for reasons of safety — can appear maladaptive from outside the context of the abusive relationship.

Bassett recalls a client who talked about agreeing to meet her estranged husband at a public library. Without understanding the full context of the situation — that if she didn’t meet with him, he had a history of escalating — a counselor might assume that the client was complicit in maintaining the abusive relationship rather than appreciate her layered safety planning, Bassett says.

“It was a brilliant move. It was safe to meet there because he couldn’t escalate without drawing attention,” Bassett explains. “Not meeting him just was not possible. This was meeting on her terms versus his terms. … This ties into [a counselor] listening and really hearing what the person is saying and not judging it out of context. Really being able to say, ‘That is a brilliant idea that you had.’ It’s not a good or a bad choice. Instead say, ‘When I hear that, I hear the safety it creates.’”

Victims of abuse often adopt patterns and behaviors that are the best choices they can make in a bad situation, Bassett notes. Professional clinical counselors should listen carefully to understand the full context of clients’ lives and then validate the choices they are making to safely navigate abusive and potentially violent situations. “Respect that they’re making a decision and really understand their safety concerns so your intervention is helpful and doable,” Bassett says.

Power and control

IPV happens between partners of all cultures and backgrounds — couples who are married and unmarried, heterosexual and homosexual, wealthy and poor, religious and nonreligious, white, Asian, Hispanic, African American and every other race. In addition, IPV often intersects with sexual assault; homelessness or disruptions in housing, schoolwork or employment; financial trouble; parenting issues; and myriad other challenges that spill over into the mental health issues that commonly bring clients to counseling.

Although the terms domestic violence and intimate partner violence both include the word “violence,” the abuse doesn’t always have a physical component, or the violent behavior is combined with emotional, nonphysical manipulation. What defines a behavior or relationship as abusive is a common thread of power and control. In its simplest definition, domestic violence is an intentional pattern of behaviors used by the abuser to gain and maintain power and control over another person, Cameron explains.

“It’s important to recognize that abuse is not an anger management issue,” she says. “People who are truly experiencing an anger management issue will go off on their boss, their cousin, the random guy at 7-Eleven. Abuse is carefully targeted at one person.”

Controlling behaviors are one of the biggest red flags counselors should be listening for to determine if a client might be involved in an abusive relationship, either as a perpetrator or a victim. Examples include checking or monitoring a partner’s cell phone, email or social media, or insisting that a partner text when they arrive at and leave from work every day. Other cues for which Cameron stays alert include:

  • Clients who clam up in session or appear to be afraid of their partner
  • Clients who are isolated from friends and family
  • Clients who feel they can’t go to work, school or social engagements because it upsets their partner
  • If one partner is the sole decision-maker or in complete control of the couple’s finances
  • If one of the partners continually feels guilty for their behavior
  • A partner who exhibits extreme jealousy
  • Clients who mention “walking on eggshells” around their partners
  • Clients who are having thoughts of suicide or threatening to harm themselves or their abuser
  • A partner who pressures the other partner to use drugs or alcohol or to not use contraception (or who lies about their own use of contraceptives)
  • A partner who pressures the other partner to have sex or to perform sexual acts that the person is uncomfortable with
  • Clients who talk about a partner belittling or embarrassing them in front of other people

Control tactics often go hand in hand with perpetrators minimizing or placing blame for their behavior, Cameron adds. Perpetrators of abuse may tell a victim that they wouldn’t have to act this way if the person came home from work on time, paid the bills on time, didn’t talk back, etc. Or, Cameron says, they may tell a partner, “It could have been a lot worse. I only shoved you. I didn’t punch you.”

In counseling, perpetrators may make statements such as, “I didn’t hurt her. I just punched the wall.” The behavior implies, however, that the perpetrator could have hurt the person, Cameron points out.

“Someone who is abusive will try and deflect attention away from the abuse,” Bassett says. “They will try and name what is happening. Maybe they push or strangle or pull their partner’s hair. But they will say, ‘I am not abusive because I never hit you. Have I ever hit you?’ or [point out that] there was no bruise. There’s a lot of crazy-making behavior that goes on. They’ll deny it ever happened or focus on something else. Abuse is a pattern of behavior, and the abuser will rationalize those patterns as something else. Pay attention to that as a therapist and help them to name the behavior [for what it is].”

If a client mentions that they fight a lot with their partner or that the partner has a temper or a “short fuse,” counselors can prompt the client to explain the fights, Cameron says. For example, “Tell me what these fights look like. Are there times [when] it feels unsafe?” Victims may use phrases such as “sometimes he is rough with me” or he “put hands on me,” not fully recognizing the behavior as abuse, she notes.

Carlson also recommends that counselors use carefully worded questions to follow up on statements made by clients to further explore the nature of their relationship experience. For example, ask clients how they handle conflict with an intimate partner and then use leading questions to learn more: When there is a disagreement, is it safe to talk about the disagreement? Is there any type of pushing, shoving, hitting, use of objects, physical violence, threatening language or name calling? Is jealousy a motivating factor? Does one partner place blame on the other, making statements such as, “You made me do this”? Is the partner violent or hostile outside of the relationship?

“Ask questions that determine if there is regret or remorse [after conflict] or if they recognize that there are other ways of handling conflict,” Carlson says.

In sessions with individual clients, Carlson recommends that counselors preface some of their most direct questions — such as “Are you afraid of your partner?” — with dialogue that prepares the client. “Say, ‘I have some questions for you about how you handle conflict in your relationship. They’re going to be very direct, and I wanted to give you a heads up, but it will help me better understand what you’re going through.’ Really tap into your basic counseling skills, the relationship-building skills that we learn early on, and emphasize those when such important questions are being asked,” Carlson says.

At the same time, Bassett adds, clinical counselors shouldn’t be afraid to ask hard questions of a client when appropriate. “Ask not just, ‘Has your partner physically assaulted you?’ but ‘Are you afraid of your partner?’ and be willing to explore that. Explore the emotional piece of abuse.”

Counselors can also supplement their own questions by using a formal questionnaire — Carlson recommends Brian Jory’s Intimate Justice Scale — or including questions on intake forms. Keep in mind, however, that clients may answer “no” to questions that later turn out to be a “yes” when explored in therapy.

Perpetrators of domestic violence often use manipulation to gain and maintain control over a person and keep them in the relationship, Cameron says. When alone with a partner, perpetrators sometimes threaten suicide if the partner ever were to leave them, or they make statements inferring that the partner would be worse off on their own: “If you leave, you won’t get any money”; “You will lose the kids”; “No one will ever love you. I’m the only one who will put up with you.”

“One of the biggest power tools is fear — abusers wield fear,” Cameron says. “They use fear to control their partner. In addition, abusers will often apologize for the abuse and say, ‘It will not happen again,’ without being accountable. Then they continue using control tactics.”

This can be complicated further if the couple’s friends and family take sides or if the victim comes from a culture or faith community that emphasizes submission to a partner, views marriage as an unbreakable bond, or values reconciliation over safety, Cameron adds.

Manipulation by a perpetrator can also extend to sexual assault, which often overlaps with domestic violence, Bassett says. “It’s also common for an abusive person to force or pressure sex [with an intimate partner]. They will define the experience as nonabusive and lay the groundwork for the survivor to agree to sex so that they aren’t forced,” she says. “The abuser is [then] able to say that they agreed to sex, making them complicit in what is actually a sexual assault. The abuser defines the experience, and the survivor needs the space and safety to name their experience [in counseling].”

Hard questions, empathetic listening

Most of all, clients who are currently in or have been in an abusive relationship in the past need a safe space to feel heard and validated and to be connected to resources to address their safety, Cameron says. It’s no surprise that building a therapeutic bond is especially important with these clients.

“Communicate that you believe them,” Cameron urges. “The most restorative thing [for the client to hear is] ‘it’s not your fault, and it’s not OK that they are doing this to you.’”

“It’s incredibly important to be nonjudgmental,” agrees Carlson. “There are so many practitioners who have a personal connection to this topic, it can be an emotive experience. The time of disclosure is a very important moment for the victim and can be filled with a lot of embarrassment and shame. When they are deciding how much to disclose, it’s often based on how they feel it will be received. … It’s important to manage your emotions in that moment because it’s such an important moment.”

“You may leave the room and feel, ‘Oh my gosh, this is an emergency. I have to get this person out.’” Carlson continues. “But remember that this is their daily reality. They’ve been living with this [abuse] for a while. It feels like an emergency to you, but to act on that may put the victim in danger. It’s important that the victim drives the steps of what happens next.”

Bassett agrees: “Be very aware that your goal [as a counselor] is not that they should leave the relationship. That needs to be a goal they make themselves. They have to own it, because any decision they make will potentially have ramifications for them.”

Cameron notes that taking decisions out of the hands of clients is one of the worst mistakes counselors can make when working with victims of IPV. “They’ve already had someone control their life, and we don’t want to step into that role,” she says. “The victim has the best knowledge about what they need.”

It’s vital for practitioners to explore a client’s experience with genuine care, says Paulina Flasch, an ACA member and an assistant professor in the professional counseling program at Texas State University. “Really show concern and empathy and don’t sound like you’re interrogating them,” says Flasch, who runs a family violence research team at Texas State and worked at a domestic violence agency before and during her master’s program. “Focus on the counselor-client relationship, and ask [hard questions] because you really care. Share that what you’re hearing sounds abusive and that it must have been really hard [to go through]. … If you’re hearing that a past relationship was abusive, it’s important to call it that and identify its aftereffects. It can help validate their current experience and help them understand why they’re struggling. Help them look at patterns and how things tie together. … It’s a very powerful moment when the client connects the dots.”

“This is a person whose boundaries have been violated and who has not had safety and security — and we [counselors] have to be careful with that,” Flasch continues. “We have to let them know there will be a different response and they won’t be demeaned. If they went through that, they’re strong. Recognize that.”

All of the counselors interviewed for this article recommend using psychoeducation techniques and the Power and Control Wheel system (available at theduluthmodel.org) to talk through what a healthy relationship looks like (and does not look like) with clients who have experienced IPV. Bassett also stresses that work with IPV clients must be trauma-informed.

Emotionally focused therapy (EFT), expressive therapies, bibliotherapy or cinematherapy, grounding techniques and decision-making exercises can also help IPV clients, Flasch notes, as can attending support groups for IPV survivors in addition to counseling.

Victims of domestic violence often grapple with intense feelings of guilt or shame, sometimes made worse by harmful stereotypes and society’s general misunderstanding of the complexity of abuse. Victims can hear messages such as “Why didn’t you just leave him?” or “Why didn’t you get out sooner?” in both direct and indirect ways in popular culture, from family and friends, or in offhand remarks by acquaintances.

The reality is that it’s not that simple, Flasch notes. Victims of domestic violence are in the most danger when they are ending a relationship with their abuser (see sidebar, below). In addition, domestic violence often creeps into a relationship slowly over time in ways that are unrecognizable to the victim.

The relationship “hasn’t always been dangerous,” says Flasch, who has a private practice in Austin, Texas, and specializes in working with couples and individuals who have experienced trauma. “There have been a lot of pieces that have kept them in the relationship. If they had known this was going to happen, they would have never been in the relationship. Intimate partner violence is the breaking down of a human. They completely lose their sense of self and begin to believe everything the abuser has said about them. It happens smally and slowly.”

Pointing out this trajectory to the client emphasizes that it wasn’t their fault and helps them learn what to look for in future relationships, Flasch adds. “Normalize it with the client. This [IPV] is very common and very similar in the ways it comes to happen,” she says. “It’s a systematic breakdown of a person that happens in very small steps that no one would recognize unless you know what you’re looking for. Helping them understand what and how it happened can help take away some of that fault and blame. Then work on empowerment. Victims have had to ask their abuser for everything. It’s our job to get their voice back.”

Planting seeds

In addition to providing a safe space to be heard and empowered, counseling can be a place for victims of IPV to learn what a healthy relationship looks like. This is especially true for clients whose histories include past trauma (in addition to IPV) or who haven’t been exposed to healthy relationships in their life, Flasch notes.

“The counselor may be that first one, that first good relationship and having a feeling of being in a room with someone who cares,” she says. “Model that through your interaction with clients. Psychoeducation is a big part of working with [IPV] victims and survivors.”

Flasch suggests using the Power and Control Wheel while discussing what it feels like to be in a healthy relationship: What aspects are present? What does respect look like? How do arguments start and end? What does equality look like?

Making a list of the elements in a healthy relationship can also help, Flasch says. “It’s not tangible [to clients] sometimes. There’s so much self-blame and lack of trust of themselves and their own instincts. They often don’t trust themselves to make decisions or recognize if something [in a relationship] is dangerous.”

It can also be helpful for counselors to talk through boundary issues with IPV survivors, including what is and isn’t their responsibility in a relationship, Bassett adds.

“With someone who is abusive, that person will not accept responsibility [for abusive behavior]. The person who is being abused typically will accept full responsibility,” she says. “They may claim, ‘Oh, he’s Dr. Jekyll and Mr. Hyde. He’s so sweet, but when he drinks, or goes off his medication [he turns dangerous].’ That’s just not true: The good parts and the loving parts are part of the [control] strategy. Be very clear about that. … Help them not to buy into it, overtly or covertly.”

Couples counseling and safety

A relationship in which IPV is present has, at its core, an imbalance of power and control. This imbalance makes couples counseling an unsafe environment for the person experiencing the abuse, Carlson stresses. If a counselor is working with a couple exhibiting signs of IPV, he or she should take steps to terminate couples counseling as soon as possible while ensuring the victim’s safety, Carlson says.

“If power and control exist in the couple’s dynamic, it’s generally not safe to be in a setting [i.e., couples counseling] where they’re both on equal ground being asked to practice healthy behaviors and make changes,” he explains. “That can’t happen when there’s inequality.”

Cameron agrees. “Each session is posing a safety risk for the victim. In couples counseling, we’re asking both parties to be accountable for solving problems in the relationship, and part of the control tactics [of IPV] is making the victim feel that it’s their fault.” Perpetrators of abuse may retaliate against their partners after counseling sessions in reaction to what was said or disclosed, she says.

On the flip side, abuse victims may say only what they need to say to keep from “making waves” with their abusers during counseling sessions. In addition, “an abuser may be very charming and manipulate the counselor,” Cameron says. Counselors who don’t recognize the manipulation or other possible indicators of IPV can end up unintentionally colluding with the abuser, she points out.

Both Cameron and Carlson recommend that counselors — whether they work with couples or individuals — seek training on IPV to stay informed on best practices and forge connections with local domestic violence agencies. It is important to establish these working relationships ahead of time so that counselors can readily consult with specialists when they identify signs of IPV with a client (or a couple) on their caseload, Carlson says. “Consultation [with an IPV specialist] helps to create a methodical, well-thought-out plan for that point forward,” says Carlson, noting that any consultation must be done within ethical guidelines and without sharing any identifying details about the individuals involved.

Once a counselor has identified that IPV is present in a relationship, the steps to terminate couples counseling must be handled delicately. Counselors should never let the abuser know that they suspect abuse is taking place, Cameron emphasizes. At the same time, a fine balance must be maintained to ensure that a victim doesn’t lose contact with the counselor and is connected to resources before couples counseling is terminated.

“Never confront abuse head-on with both parties in the room. That will put the survivor at risk,” Cameron says. “Get creative for ways to get the survivor alone. … Come up with a reason to separate them and then check in with the survivor. Ask them if they feel safe at home. Just straight up asking if they are being abused — they are not going to recognize it that way. Often, the abuser has worked really hard to convince the victim that there is no abuse.”

Cameron has known counselors who separate the couple by asking one of the partners to fill out paperwork in the waiting room. Practitioners can also try to speak over the phone outside of session to clients who are suspected targets of abuse, as long as they ensure the client is alone for the call, Cameron adds.

Carlson notes that it’s not uncommon in couples counseling for a practitioner to meet with one of the clients individually to work on an issue. Counselors can fall back on that as an excuse to separate a couple when it is suspected that IPV is present, he says.

“When [you] first meet with a couple, separate them to fill out an intake questionnaire and speak with them individually. That way, you set a precedent of talking separately,” Carlson says. “Then, you can say later, ‘We are going to meet individually to follow up on some of the things we talked about’ [at intake]. There is precedence, and it doesn’t seem out of the ordinary.”

Flasch agrees and suggests that couples counselors do full individual sessions with both partners after the first two or three sessions, regardless of whether IPV is suspected. In these sessions, counselors should always assess for IPV. She suggests asking questions such as “How do you and your partner show respect for each other?” and “Tell me about your arguments: How do they start and end, and who initiates?”

A counselor’s next step should be to connect the victim with local support services. This must also be handled carefully, Cameron says. For instance, a client could put a domestic violence hotline number in their phone under another name, or the counselor could give the information verbally to the client to remember and look up later. Cameron also recommends that counselors leave pamphlets and other information about domestic violence resources in the lobbies and restrooms of their offices for all clients to see and have access to.

If appropriate, Cameron recommends that counselors also connect perpetrators with a local batterer or offender program.

“It’s important to work in collaboration with your local [domestic violence] agency,” Cameron says. “For us to address abuse in our communities, there needs to be community accountability for abusers, and that can’t just come from domestic violence agencies. It needs to come from all aspects of the community. You’re not going to end domestic violence just by dealing with the aftermath.”

Once clients are given information about IPV resources, it’s up to them to seek help when they are ready and feel safe doing so, Carlson adds. It’s not a counselor’s role to ensure the client has followed up with those resources.

“Sometimes nothing happens,” Carlson acknowledges. “You present resources and opportunities and they know they have options, and that’s the biggest step they want to take at this point in time.”

Relationships post-IPV

Dating and forming new relationships can play a part in the healing process for survivors and help them learn more about themselves, their boundaries and their limits, says Flasch, who co-authored the article “Considering and Navigating New Relationships During Recovery From Intimate Partner Violence” in the April issue of the Journal of Counseling & Development. Counselors should be aware that the risk exists for survivors of IPV to find themselves in another abusive relationship. However, forging new healthy relationships — with a counselor as a support and ally — can be a helpful step in the right direction, she notes.

“Survivors have to work through these issues for a lifetime, so waiting for the ‘right time’ to date post-healing may never come,” Flasch says. “A counselor can be a great support for a survivor. We know that most people continue to date. To say that you should be healed completely before you go out, it’s not realistic. And healthy relationships can be incredibly healing. Having a person who is safe and loving and accepting is a huge benefit. We [counselors] shouldn’t necessarily discourage dating but help them navigate the process. Educate them about red flags and warning signs, and celebrate the successes of milestones reached through dating. Also [process] triggers and things that get in the way.”

“Having experiences with other people and then processing it in counseling can be very powerful and helpful to healing,” she continues. “We can be great allies and celebrate with clients when they try something new.”

For the journal article, Flash and her co-authors studied the experiences of IPV survivors who went on to try new relationships, ranging from casual dating to marriage. Through these relationships, participants reported learning to trust themselves and their instincts and “reclaim parts of themselves lost during the IPV relationships,” Flash wrote with her co-authors, David Boote and Edward H. Robinson.

Dating post-IPV “can be a process for survivors to try and find corrective experiences and explore trust, make decisions that are theirs and be their own person, [and] learn about control and boundaries,” Flasch says. “But this is also a very scary process and one that has a lot of layers to it, so it can bring challenges. It can be hard to learn to trust when it’s been taken away from you in the past.”

 

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IPV: Need-to-know points for counselors

One of the most misunderstood aspects of intimate partner violence (IPV) is how complicated and dangerous leaving an abusive partner can be, says Taylor Cameron, a licensed professional counselor (LPC) and director of transitional housing at a Texas nonprofit that provides support services to victims of domestic violence and sexual assault. The power imbalance of abusive relationships often means that one partner has severely restricted the other’s access to finances, friends and family members, and community resources. Separating from an abuser often means starting life over, which is why there is an intersection of IPV and homelessness, she says. These factors are only exacerbated when children are involved or when the victim experiences other forms of systemic oppression such as racism, homophobia or classism.

“They are often trapped between violence and homelessness,” Cameron says. “The abuser has often messed up their credit and finances or totally controlled them, so they’re starting from scratch. The most dangerous time for a victim is during separation and when they are separated [because] the abuser is losing the power they have worked to gain and maintain.”

According to Cameron, IPV victims are at the highest risk of lethality under the following circumstances:

  • When the couple has separated or is in the process of separating
  • If sexual abuse or sexual coercion is present in the relationship
  • If an abuser makes threats of homicide or suicide
  • When a restraining order is filed
  • If the victim is pregnant
  • If strangulation is occurring
  • If violent behavior is occurring outside of the home (which indicates the abuser has escalated to the point where he or she does not care if other people see the behavior, Cameron says)
  • If there is involvement with child protective services
  • If the abuser has access to weapons
  • If the abuser exhibits stalking behaviors
  • If law enforcement is involved

Counselors should also keep in mind that even when victims leave an abusive relationship, they may still come in contact with their abusers — and be put at risk for retraumatization — through legal proceedings, child custody hearings or stalking behavior, adds Paulina Flasch, an assistant professor in the professional counseling program at Texas State University.

“Just because someone is no longer in an IPV relationship doesn’t mean they’re no longer in it. Remember that and equip them with tools [to cope],” Flasch says.

 

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Important resources

 

Margaret Bassett recommends the following books for practitioners:

  • Why Does He Do That? Inside the minds of angry and controlling men by Lundy Bancroft
  • Battered Women’s Protective Strategies: Stronger Than You Know by Sherry Hamby
  • Coercive Control: How Men Entrap women in Personal Life (Interpersonal Violence) by Evan Stark
  • Safety Planning with Battered Women: Complex lives/Difficult Choices by Jill Davies, Eleanor J. Lyon and Diane Monti-Catania
  • The Verbally Abusive Relationship by Patricia Evans
  • Domestic Violence Advocacy: Complex lives/Difficult Choices by Jill Davies and Eleanor J. Lyon

 

Related reading, from Counseling Today:

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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.

What’s left unsaid

By Lindsey Phillips January 3, 2019

A child discloses that her grandfather has been sexually abusing her, and the mother’s response is shock that his abuse didn’t stop with her when she was a child. This scene is not uncommon for Molly VanDuser, the president and clinical director of Peace of Mind, an outpatient counseling and trauma treatment center in North Carolina. As she explains, adult survivors of child sexual abuse often assume that the offender has changed or is too old to engage in such actions again. So, the abuse persists.

Concetta Holmes, the clinical director of the Child Protection Center in Sarasota, Florida, has treated clients with similar intergenerational abuse stories. “In that unresolved trauma … what has happened is now a culture of silence around sexual violence that is ingrained in the family,” she says. “That [affects] things like your feelings of safety, security [and] trustworthiness, and it reinforces that you should stay with people who hurt you.”

Kimberly Frazier, an associate professor in the Department of Clinical Rehabilitation and Counseling at Louisiana State University’s Health Sciences Center, acknowledges that people often don’t want to think or talk about child sexual abuse, but that doesn’t stop it from happening. The nonprofit Darkness to Light reported in 2013 that approximately 1 in 10 children will be sexually abused before they turn 18.

Because of the culture of silence that surrounds child sexual abuse, it is safe to assume that the true number is even higher. Cases of child sexual abuse often continue for years because the abuse is built on a foundation of secrets and fear, Frazier points out. Survivors frequently fear what will happen to them (or to others) if they tell, or the shame they feel about the abuse deters them from disclosing.

Societal norms can also diminish a survivor’s likelihood of disclosing. For example, society has for decades implicitly sanctioned sexual interactions between boys who are minors and adult woman, but it is still abuse, says Anna Viviani, an associate professor of counseling and director of the clinical mental health counseling and counselor education programs at Indiana State University. Holmes adds that gender stereotypes such as this can cause boys to feel as though they shouldn’t be or weren’t affected by sexual abuse, which is not the case.

“I think the biggest fallacy [counselors have] is that [child sexual abuse] is going to impact people from a particular demographic more than another,” Viviani says. “Childhood sexual abuse cuts across every demographic. I think the sooner we can accept that, the sooner we’re going to be better at identifying clients when they have this issue in their history.”

Putting on a detective hat

Identifying signs of child sexual abuse is neither easy nor straightforward. Part of the difficulty lies in the fact that the signs are not clear-cut, says VanDuser, a licensed professional counselor (LPC) and an American Counseling Association member. Regressive behaviors such as bed-wetting can indicate abuse, but they might also be the result of other changes such as a recent move, a new baby in the family or a military parent deploying, she explains.

VanDuser also warns that child sexual abuse is insidious because a lot goes on before the offender actually touches the child. “Childhood sexual abuse sometimes leaves no physical wounds to identify,” she says. Some examples of noncontact abuse include peeping in the window at the child, making a child watch pornography or encouraging a child to sit on one’s lap and play the “tickle game.” Such activities are part of the grooming process — the way that offenders build trust and gain access to the child.

In addition to physical signs such as bladder and vaginal infections, changes in eating habits, and stomachaches, survivors of child sexual abuse also demonstrate behavioral and emotional changes. One major warning sign is if the child displays a more advanced knowledge of sex than one would expect at the child’s developmental stage, VanDuser says.

Other possible behavioral signs include not wanting to be alone with a certain person (e.g., stepfather, babysitter), becoming clingy with a nonoffending caregiver, not wanting to remove clothing to change or bathe, being afraid of being alone at night, having nightmares or having difficulty concentrating. In general, counselors should look for behaviors that are out of character for that particular child, VanDuser advises.

Viviani, a licensed clinical professional counselor and an ACA member, also finds that people who have experienced child sexual abuse have higher rates of depression, anxiety, panic disorders and posttraumatic stress disorders.

Because the signs of child sexual abuse are rarely clear-cut, counselors must be good investigators, Viviani argues. In her experience, adult survivors present with an array of symptoms, including health concerns, relationship problems and gaps in memory, so counselors have to look for patterns to discover the underlying issue.

If counselors notice any of these signs, VanDuser recommends asking the client, “When did this problem (e.g., bed-wetting, cutting, nightmares, acting out in school) begin?” Counselors can then follow up and ask, “What else was going on at that time?” The answers to these questions often reveal the underlying issue, she notes. For example, if the client responds that his or her depression or vigilance to the environment began around age 12, VanDuser says she will dig deeper into the client’s family relationships.

Frazier, an LPC and a member of ACA, suggests that counselors can also look for patterns in a child’s drawing — for example, what colors they use, how intensely they draw with certain colors, or if they scratch out certain people or choose not to include someone — or in the choices children make with activities such as feeling faces cards (cards that depict different emotional facial expressions). When Frazier asked one of her clients who had come to counseling because of suspected sexual abuse to select from the feeling face cards, she noticed the client consistently picked cards with people wearing glasses. Frazier later discovered that the child’s abuser wore glasses.

For Frazier, becoming a detective also involves going outside of the office to observe the child in different spaces, such as in school, in day care or at the park. Frazier includes the possibility of outside observations in her consent form, so the child’s parent or guardian agrees to it beforehand. She advises that counselors should take note of whether the child’s behavior is consistent across all of these spaces or whether there are changes from home to school, for example. In addition, she suggests asking the parents or guardians follow-up questions about how the child’s behavior has changed (e.g., Has the child lost the joy of playing his or her favorite sport? Is the child withdrawn? Is the child fighting?).

Speaking a child’s language

Young children may not have the words or cognitive development to tell counselors about the abuse they have been subjected to. Instead, these children may engage in traumatic play, such as having monsters in the sand tray eat each other or being in a frenzied state and drawing aggressive pictures, VanDuser says.

“One of the most important things for clinicians to remember when they’re working with kids and abuse is that it’s really critical to be working within the languages that children speak,” says Holmes, a licensed clinical social worker and a nationally credentialed advocate through the National Organization for Victim Assistance. “Children speak through a variety of different languages that aren’t just verbal. They speak through play. They speak through art, through writing [and] through movement, so it becomes really important that clinicians get creative in using evidence-based practices and different modalities to talk with children through their language. … Talking in a child’s language allows them to feel like the topic at hand is less overwhelming and less scary.”

For example, children can use Legos to build a wall of their emotions, Holmes says, with counselors instructing clients to pick colors to represent different emotions. If orange represents sadness and red represents frustration and 90 percent of the child’s wall contains orange and red Legos, then the counselor gets a better visualization of what emotions are inside the child, she says.

Next, counselors could ask clients what it would take to remove a red brick of frustration or what their ideal wall would look like, such as one that contains more bricks representing happiness or peace. Counselors can also ask these clients to rebuild their Lego walls throughout therapy to see how their emotions are changing, Holmes says. This method is easier than asking children if their anger has decreased and by how much, she adds.

Frazier, past president of the Association for Multicultural Counseling and Development, a division of ACA, also finds that working with children keeps counselors on their toes. Children are honest and will admit if they do not like an intervention, so counselors have to be ready to shift strategies quickly, she says. For this reason, counselors need to have a wide range of creative approaches in their counseling bag. She recommends drawing supplies, play school or kitchen sets, play dough and sand trays.

With sand trays, Frazier likes to provide dinosaurs and other nonhuman figurines for children to play with because it helps them not to feel constrained or limited. This allows them to freely let a dinosaur or car represent a particular person or idea, she explains.

Frazier also recommends the “Popsicle family” intervention, in which children decorate Popsicle sticks to represent their family members and support systems. This exercise provides insight into family dynamics (who is included in the family and who isn’t) and allows children to describe and interact with these “people” like they would with Barbie dolls, she says.

Frazier advises counselors to keep culturally and developmentally appropriate materials on hand. For example, they should have big crayons for young children with limited fine motor skills, and they should have various shades of crayons, markers, pencils and construction paper so children can easily create what they want.

Being multiculturally competent goes beyond ethnicity, Frazier points out. Counselors should understand the culture the child grew up in and the culture of the child’s current locality because what is considered “normal” in one city or area might differ from another, she says. For example, in New Orleans, where she lives, people regularly have “adopted” family members. So, if a child from New Orleans were creating his or her Popsicle family, it wouldn’t be strange to see the child include several people outside of his or her immediate family and refer to them as “cousin” or “aunt,” even if they aren’t blood relatives.

Thus, Frazier stresses the importance of counselors immersing themselves in the worldview of their child clients. “You can’t be a person who works with kids and not know all the shows and the stuff that’s happening with that particular age group, the music, the things that are on trend and the things they’re talking about,” Frazier says. “Otherwise, you’ll always be behind trying to ask them, ‘What does that mean?’”

With adolescents, Holmes finds narrative therapy to be particularly effective, and she often incorporates art and interview techniques into the process. For example, the counselor could ask the client to draw a picture of an emotion that he or she feels, such as anger. Next, the client would give this emotion a name and create a short biography about it. For example, how was anger born? How did it grow up to be who it is? What fuels it? Why does it hang around?

Next, Holmes says, the counselor and client could discuss the questions the client would ask this emotion if it had its own voice. Then, the client could interview the initial picture of the emotion and use his or her own voice to answer the questions as the emotion would. The answers provide insight into the emotional distress the client is feeling, Holmes explains.

Frazier will do ad-lib word games with older children, who are often more verbal. While clients fill in the blanks to create their own stories, she looks for themes (e.g., gloomy story) or the child’s response to the word game (e.g., eager, withdrawn). 

Long-lasting effects

Unfortunately, the effects of child sexual abuse don’t end with childhood or even with counseling. “Children revisit their trauma at almost every age and stage of development, which is every two to three years,” Holmes notes. “That might not mean they need counseling each and every time, but they find new meaning in it or they find they have new questions … or new emotions about it.”

Viviani, VanDuser and Frazier agree that recovery is a lifelong process. As survivors age, they will have sexual encounters, get married, become pregnant or have their child reach the age they were when the abuse occurred. These events can all become trigger points for a flood of new physical and emotional symptoms related to the child sexual abuse, Viviani says.

Often, an issue separate from the abuse causes adult survivors to seek counseling. In fact, VanDuser says she rarely gets an adult who discloses child sexual abuse as the presenting issue. Instead, she finds adult clients are more likely to come in because their own child is having behavioral problems or because they’re feeling depressed or anxious, they’re having nightmares or they’re married and have no interest in sex.

Adults survivors often experience long-term physical ailments. According to Viviani, who presented on this topic at the ACA 2018 Conference & Expo in Atlanta, some of the ailments include diabetes, fibromyalgia and chronic pain syndromes, pelvic pain, sexual difficulties, headaches, substance use disorders, eating disorders, cardiovascular problems, hypertension and gastrointestinal problems.

Another long-term issue for survivors is difficulty forming healthy relationships. Because child sexual abuse alters boundaries, survivors may not realize when something is odd or abusive in a relationship, VanDuser says. For example, if an adult survivor is in a relationship with someone who is overly jealous and possessive, he or she may mistakenly translate that jealously into a sign of love.

Child sexual abuse can also affect decision-making as an adult around careers, housing, personal activities and sexual intimacy, Viviani notes. For example, one of her clients wanted to attend a Bible study group but didn’t feel safe being in a smaller group where a man might pay attention to her. In addition, Viviani finds that adult survivors sometimes choose careers they are not interested in just because those careers provide a safe environment with no triggers.

To help adult clients make sense of the abuse they suffered as children and move forward, Viviani often uses meaning-making activities and mindfulness techniques. She suggests that counselors help these clients find a way to do something purposeful with their history of abuse, whether that involves sharing their story with a testimony at church, volunteering for a mental health association or participating in a walk/run to raise awareness of suicide prevention.

Finding self-compassion

Survivors of child sexual abuse often blame themselves for the abuse or the aftermath once the abuse is revealed, especially if it results in the offender leaving the family, the family losing its home or the family’s income dropping, VanDuser says. One of her clients even confessed to thinking that she somehow triggered her child sexual abuse from her stepfather.

“Sometimes the worst part is the dread [when the child knows the sexual abuse is] coming eventually. So, sometimes a teenager will actually initiate it to get it over with because the only time they feel relief is after it’s done,” VanDuser explains. “Then they know for a while that they won’t be bothered again.”

Counselors often need to shine a light on survivors’ cognitive distortions to help them work through their guilt and shame, VanDuser says. She tries to help clients understand that the sexual abuse was not their fault by changing their perspective. For example, she will take a client to a park where there are children close to the age the survivor was when the abuse happened. She’ll point to one of the children playing and ask, “What could the child really do?” This simple question often helps clients realize that they couldn’t have done anything to prevent the abuse, VanDuser says.

Viviani takes a similar approach by talking with clients in the third person about their expectations of what a child would developmentally be able to do in a similar situation. She asks clients if they would blame another child (their grandchild or niece, for example) for being sexually abused. Then she asks why they blame themselves for what happened to them because they were also just children at the time.

“As you frame it that way, they begin to have a little bit more compassion for themselves, and self-compassion is something that’s so important for survivors to develop,” Viviani says. In her experience, survivors are hard on themselves, often exercising magical thinking about what they should or should not have been able to do as a child. “As we help them develop self-compassion and self-awareness, we see the guilt begin to dissipate,” she adds.

Regaining a sense of safety

Safety — in emotions, relationships and touches — is a critical component of treatment for a child who has been sexually abused, Holmes stresses.

Counselors should teach clients about safe and unsafe touches, personal boundaries and age-appropriate sexual behavior rules, adds Amanda Jans, a registered mental health counseling intern and mental health therapist for the Child Protection Center in Sarasota. Counselors can also help clients “understand that they are in charge of their bodies, so even if a touch is safe, it doesn’t mean they have to accept it,” she says.

Hula hoops provide a creative way to discuss personal space boundaries with clients, Holmes notes. Counselors can use hula hoops of different sizes to illustrate safe and unsafe boundaries with a parent, sibling, friend or stranger, she explains.

VanDuser helps clients engage in safety planning by having them draw their hand on a piece of paper. For each finger, they figure out a corresponding person they can tell if something happens to them in the future.

Counselors can also take steps to ensure that their offices are safe settings. Jans, an ACA member who presented on the treatment of child sexual abuse at the ACA 2018 Conference, uses noise machines to ensure privacy and aromatherapy machines to make the environment more comfortable. She also has a collection of kid-friendly materials, so if a child starts to feel dysregulated during a session, he or she can take a break and play basketball or color.

Likewise, if clients are hesitant to discuss the topic, Jans allows them to take a step back. For instance, she has clients read someone else’s experience (either real or fictional) rather than having them write their own story, or she has clients role-play with someone else serving as the main character, not themselves. This distance helps clients move to a place where they eventually can discuss their own stories, she says.

Another technique Jans uses to ease clients into writing and processing their own stories is a word web. Together, Jans and a client will brainstorm words related to the client’s experience and put the words on a web (a set of circles drawn on a paper in a weblike pattern). Jans finds this exercise helps clients get comfortable talking about the subject and, eventually, these words become part of their narrative.

VanDuser also suggests getting out of the office. Sometimes she takes child and adolescent clients to a store to get a candy bar. On the way, she will ask them what they are feeling or noticing. If clients say that someone walking by makes them feel strange, VanDuser asks how they would address this feeling or what they would do if someone approached them. Then they will talk through strategies that would make the client feel safe in this situation.

Taking back control

Survivors of child sexual abuse often feel they can’t control what happens around them or to them, Frazier says. So, counselors can get creative using interventions that return control to these survivors and make them feel safe.

Viviani helps clients regain some sense of control in their lives by teaching grounding and coping skills. “Coping skills are so important to helping them begin to trust in themselves again so that they have the skills to really uncover and deal with the abuse,” she explains.

In sessions, counselors can help clients recognize what their bodies feel when they are triggered. Then they can help clients learn to deescalate through grounding skills such as noticing and naming things in their current surroundings or reminding themselves of where they are and the current date, Viviani says. Rather than reliving the incident — being back in their bedroom at age 5, for example — clients learn to ground themselves in the here and now: “This is Jan. 10, 2019, and I’m sitting in my office.”

VanDuser highly recommends trauma-focused cognitive behavior therapy (TF-CBT) for work with survivors of child sexual abuse. TF-CBT is a short-term treatment, typically 12-16 sessions, that incorporates psychoeducation on traumatic stress for both the child and nonoffending parent or caregiver, skills for identifying and regulating emotions, cognitive behavior therapy and a trauma narrative technique.

For a creative approach, VanDuser suggests letting children use crayons and a lunch bag to create a “garbage bag.” She first writes down all the bad feelings (e.g., fear, anger, shame) the client has about the abuse. As the child finishes working on one of the bad feelings, he or she puts the feeling in the garbage bag. When all the feelings are in the bag, VanDuser lets the client dispose of it however he or she wishes — by burning it, burying it, throwing it in the actual garbage or some other method.

Jans and Holmes suggest empowering clients by giving them some control in session. For example, if clients are feeling sad, the counselor can remind them of the coping strategies they have been working on (perhaps progressive muscle relaxation and grounding techniques) and ask which one they want to use to address this feeling. The counselor could also list the goals of therapy for that day and ask clients which one they want to work on first, Holmes says.

Holmes acknowledges that clients may never make sense of the abuse they suffered, but counselors can help them make sense of the abuse’s impact and aftermath. For Holmes, this meaning making involves clients being empowered to reclaim their lives after abuse rather than being held hostage by it, realizing that trauma doesn’t have to define them and learning to be compassionate with themselves.

The hero who told

Holmes encourages counselors not to shy away from discussing child sexual abuse. “If clinicians hesitate, clients will hesitate. If the clinician avoids it, the client will avoid it,” Holmes says. “It’s the clinician’s responsibility to take the lead on this topic. Sexual abuse is so widespread in our society that we do our clients a disservice when we don’t incorporate sexual abuse histories into our [client] assessments.”

Typically, however, counselors are not the first person a child will tell about the abuse. Often, children first disclose the abuse to a teacher or other school personnel, and their reaction is crucial in ensuring that the child gets help, Viviani says.

Thus, she advises counselors to partner with schools and child advocacy organizations to educate them on what they should do if a child discloses sexual abuse. “They need to know what to do,” Viviani emphasizes. “They need to know what to say to support that child because we may not get another chance, at least until they hit college age when they’re not under that roof anymore, or we may never get that chance again.”

Counselors must also empower survivors of child sexual abuse. “They shouldn’t be waiting for the therapist … or their best friend to ride in and save them. We want them to be the hero of their own story,” Holmes says. “And how we do that is through finding ways they can start to recognize and make safe and healthy decisions about different pieces of their life, and we want to model that even within the therapy environment.”

The end result of TF-CBT is the child writing his or her own narrative of the sexual abuse. VanDuser emphasizes that no matter how the child’s sexual abuse story begins, it always has the same ending: the hero — the child — who told.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editorct@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.

Talking about #MeToo

By Laurie Meyers August 31, 2018

In 2006, activist Tarana Burke founded the “me too” movement — a grassroots campaign to help survivors of sexual violence, particularly young women of color from low-wealth communities. Over time, the movement with a simple message — you are not alone — built a community of survivors from all walks of life.

In fall 2017, in the wake of allegations of sexual assault and harassment by film producer and entertainment mogul Harvey Weinstein and other powerful men, “me too” went viral — and global — with a single hashtag. Social media feeds were suddenly flooded with #MeToo, sometimes accompanied by personal stories or alternately issued as a statement in itself.

In the year that has followed this mass call for awareness, stories of sexual harassment and assault have continued to come to light. The discussions about how to achieve safety and equality show no signs of flagging. Some of these conversations are happening in counseling practices as counselors help clients process their own #MeToo stories.

For licensed professional counselor (LPC) Sarah Kate Valatka, a private practitioner in Blacksburg, Virginia, the most striking element of #MeToo has been the sense of community — albeit an unchosen one — the movement has created for survivors. That feeling of community not only helps clients feel less isolated but also engenders hope as they see other survivors navigating their own trauma, says Valatka, an American Counseling Association member whose practice specialties include addressing gender-based violence.

Other counselors say the movement is encouraging women who previously chose to remain silent about their experiences to seek help. “I absolutely believe this has empowered more women to come forward,” says Brooke Bagley, an LPC at the Sexual Assault Center of East Tennessee in Knoxville. “I have heard the narrative repeatedly — that many have been scared, isolated or unsure of the legitimacy of their own traumas, and this movement has given these individuals a voice.”

Indeed, Bagley says although the practice where she works has not seen a substantial increase in new clients, a number of people who had not previously thought of themselves as survivors have come in looking for help to process their experiences.

Charity Hagains, a licensed professional counselor supervisor who specializes in sexual trauma, says she and other counselors at the Noyau Wellness Center in Dallas have seen many new clients seeking help not for assault but for experiences they are just now realizing had crossed the line into sexual harassment. Hagains says she has commonly heard statements from clients such as, “It never occurred to me that this [behavior] wasn’t OK. Every boss I have ever had commented on my body.”

Hagains says the #MeToo movement has also caused many adult women to reconsider their younger experiences. Typical incidents these women have shared in session with Hagains include being pressured to show their bodies in a chatroom when they were preteens or being coerced into having sex as teenagers. At the time, they didn’t consider it coercion because they thought they were old enough to consent or had been drinking and thus excused the other person’s actions.

“It always made me feel awful,” clients have told Hagains. “I was ashamed, but I didn’t realize that it was something that other people would see as not my fault.”

Conversations such as these — both inside and outside of counselors’ offices — are long overdue, asserts Laura Morse, an LPC who specializes in relationship and sexual issues, including assault and trauma. Telling these stories has served to highlight how often sexual assault occurs, but clients are grappling with what comes next, she says.

“So much of the counseling journey with sexual assault survivors is figuring out the ‘and’ after identifying with #MeToo,” says Morse, a private practitioner in Lancaster, Pennsylvania. “Empowering individuals after assault to write their narrative, decide their legal choices and how or if they want to share their story, that’s the part of the conversation that #MeToo leaves us grappling with as a community.”

Moving on from #MeToo

The journey to healing from sexual trauma often begins with defining what has happened to the client, Bagley says. Using psychoeducation, she talks to clients about what constitutes sexual assault or harassment. She also explains common reactions and responses to sexual trauma. Once clients have a better understanding of what they have experienced, Bagley says she can delve into how their trauma is manifesting and work toward the management of symptoms.

Shame and guilt often accompany sexual assault and can be difficult to move past, says Trish McCoy Kessler, an LPC and owner of Empower Counseling, a practice in Lynchburg, Virginia, that focuses on the needs of women and girls. She starts by normalizing what clients are feeling and emphasizing that the sexual violence or harassment they have experienced is not their fault.

Kessler, a member of ACA, uses cognitive behavior therapy to help clients note when they experience a negative emotion and identify the thoughts that are evoking that feeling. She then challenges those thoughts, asking clients to consider whether any evidence exists to support their negative self-talk. Simply instilling hope in clients that their feelings of shame and guilt will lessen over time can help reduce their anxiety and stress, Kessler adds.

Kessler also focuses on coping skills with clients, she says, because many people who have experienced trauma use maladaptive coping skills such as substance abuse and emotional eating. Kessler teaches clients to instead use positive skills such as meditation, reaching out to friends (to avoid isolation), listening to music and writing or journaling. She has found it especially helpful to suggest that clients (and particularly teen clients) keep a list of effective coping skills on their phones to refer to when they are feeling overwhelmed. Kessler also emphasizes the importance of self-care, including getting adequate sleep, getting the proper nutrition and engaging in regular exercise.

Hagains notes that many of her clients lack compassion for themselves. She encourages them to identify as survivors rather than victims and attempts to teach self-compassion by holding a mirror up to the compassion that her clients show to others. For example, Hagains asks clients to consider what they would say to a friend going through the same experiences. “It’s usually not something like, ‘You’re awful,’” she notes wryly. “If you would give your friend a hug, give yourself a hug,” she urges.

Hagains also asks clients to identify the shame statements that they tell themselves. Then she helps them create positive, affirming messages to replace the negative self-talk.

Over time, Bagley has created a five-phase model that she uses for clients who have experienced sexual trauma. In the first phase, she assesses and identifies the client’s level of trauma through a symptom-based checklist. She then explores the emotional, cognitive, physiological and behavioral responses the client is experiencing.

Phase 2 focuses on building rapport and establishing the therapeutic relationship. Because clients who have experienced trauma are very vulnerable, it is imperative to provide a nurturing and safe environment, Bagley emphasizes. Once she has established a bond with the client and a sense of safety, Bagley focuses on the person’s present strengths and explores how the client can use those strengths to cope with the trauma.

Bagley begins cognitive-based interventions in Phase 3. Together, she and the client identify thought distortions attached to the trauma and start practicing ways of reframing negative beliefs.

In the fourth phase, Bagley focuses on identifying specific emotions. She teaches clients to practice mindfulness by noting where on their bodies they feel certain emotions and what is happening around them when they experience these feelings. Bagley says this helps clients identify triggers and also aids in bridging the mind-body disconnect that can occur with recent sexual trauma.

In the fifth and final phase, clients build a narrative surrounding their trauma. “At this stage in the therapeutic process, clients should be displaying more stability and management of symptoms,” Bagley says. “This is often apparent through changes in the language clients use to describe their trauma experience, as well as a shift in self-view.”

At this point, Bagley has clients retell their trauma to desensitize their trauma response and to empower them to feel more in control of their story.

It takes a village

Morse often works with other professionals, including law enforcement, to help survivors of sexual violence. She tells clients there are different paths they can take as part of their treatment and asks them what makes sense or seems helpful to them. Some clients are empowered by learning about their legal rights, and the possibility of pursuing justice gives them a sense of agency. For other survivors, gaining strategies to manage anxiety is critical to their daily functioning, Morse says.

When clients choose to seek justice through the legal system, Morse offers to go to the police station with them and sit in on a meeting with detectives. Beforehand, she prepares clients by explaining that they will be asked numerous questions about what happened to them. She also educates them about how lengthy the legal process can be and the emotional toll it may take.

Many of Morse’s clients have experienced harassment at work, and in these cases, they often choose to file a complaint through their employer’s human resources department. To prepare these clients, Morse goes through their employee handbook so they fully understand the company’s harassment policies.

Morse also strives to help survivors of sexual violence feel safe again, which often requires connecting them with outside resources. She frequently recommends self-defense classes, noting that in many cities, there are now free classes offered for survivors of assault. In some cases, reestablishing a client’s sense of safety may require a change in phone number or residence.

For those who struggle with overwhelming anxiety, Morse is a big proponent of eye movement desensitization and reprocessing (EMDR), and she refers these clients to a certified EMDR practitioner. If anxiety and depression are impeding her clients’ daily functioning, she has them meet with a psychiatrist to explore the need for short-term medication management of symptoms.

Morse says group therapy can also be a crucial therapeutic tool because it provides a way for survivors to share their stories with others who have experienced sexual trauma. Many community agencies and YWCAs offer free groups, she notes.

Morse also emphasizes the power of just being there for clients. “Many survivors of assault reflect that the most helpful part of the therapeutic process is simply having someone to listen and believe them on their journey,” she says. “Oftentimes, we’ll spend several sessions talking through the details and allowing a woman to rewrite her narrative as an assault survivor.”

When #MeToo is painful

Although counselors generally say that the #MeToo movement is socially necessary and can be personally empowering, they also note that for some survivors, the constant reminders of sexual trauma can have an unintended adverse effect.

“The movement can often feel like a double-edged sword in terms of awareness for survivors,” Bagley says. Although many survivors are grateful that the truth of the widespread nature of sexual violence is being made evident, the sheer volume of stories can be overwhelming. “It floods social media, news outlets [and] radio programs, leaving little escape for survivors,” Bagley explains. “Additionally, the backlash and negative media response to the movement has … a triggering and negative impact.”

Valatka agrees. “You [a survivor] may be on social media, and it’s just a normal day. Then someone shares, and it’s bringing it into your day — bringing it to survivors when they weren’t planning for it.”

Shaina Ali, an LPC and owner of Integrated Counseling Solutions in Orlando, Florida, says that when clients who are survivors of sexual assault or harassment bring up #MeToo, she uses an existential approach. “How does this affect your story? What does this mean for you?” Ali asks clients.

Her intent is to help clients focus on how hearing these stories affects their progress. In some cases, clients realize that they have handled potentially retraumatizing information better than they thought they might, says Ali, who specializes in trauma work. For others, their reactions are an indication that they have more trauma work to do. Ali notes that some of her clients who had come to her for issues unrelated to trauma realized that the #MeToo stories mirrored their own experiences — experiences they previously hadn’t recognized they needed to talk about.

Because #MeToo and other news stories related to mental health — such as the recent suicides of Kate Spade and Anthony Bourdain — can potentially have an effect on any client, Ali always raises such topics in session. She says this serves two purposes: to check in and head off trouble before it starts and to give clients an opportunity to bring up experiences they haven’t previously been ready to share.

Sometimes the triggering comes from the casual conversation of people clients are close to, Hagains points out. As people talk about #MeToo, sexual assault and harassment survivors hear a lot of opinions being shared, some of which are full of blame. It is not uncommon to hear people say things such as, “Well, she went to his apartment, so she deserved it,” Hagains notes.

Hagains tells clients that in these cases, they need to set boundaries by telling friends or family members that they do not wish to discuss the topic and that they will have to agree to disagree. In certain cases, such as with casual Facebook friends, Hagains urges clients to decide how important it is for them to stay in contact. It may be in a client’s best interests to mute those who are making hurtful statements. Sometimes setting boundaries means limiting contact; other times it may become necessary to cease contact altogether. 

What are men learning?

The larger goal of #MeToo is to change the way that men and society as a whole see — and treat — women. Is it working?

Hagains says the topic is definitely coming up in sessions with male clients. She says that about 90 percent of the men she counsels have asked her about behavior — as in what is OK and what isn’t.

“I think a lot of men are reexamining their roles,” she says. Many of them are realizing that what they thought was appropriate or complimentary to women can actually be offensive.

A familiar refrain that Hagains hears in session from male clients who are grappling with the implications of #MeToo: “I thought women liked to be complimented on their bodies.” She responds by telling them that it might be OK to say in a bar but definitely not at work.

Ali, an adjunct professor at both Central Florida University and the Chicago School of Psychology, has also heard increased discussion from men about the topic of sexual assault and harassment, both in her practice and in the classroom. Ali teaches clients and students about harassment, setting boundaries and establishing healthy relationships.

“The way I see it,” says Kessler, “is that #MeToo is not just for women. I want men to see, this is how you treat women.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Adult Child Sexual Abuse Survivors” by Rachel M. Hoffman and Chelsey Zoldan
  • “Intimate Partner Violence — Treating Victims” by Christine E. Murray

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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.

Effective ways to approach sexual assault response

By Hasmik Chakaryan July 10, 2018

The overwhelming number of women who have participated in the #MeToo movement has drawn renewed attention to issues of sexual violence, which remains pervasive in our culture. This newly risen wave has created a refreshed platform for addressing gaps in counselor training for sexual assault response.

Even though statistics from the National Sexual Violence Resource Center show that 1 in 5 women and 1 in 71 men in the U.S. will face sexual assault at some point in their lifetime, very few counseling programs have specific courses designed for training sexual assault response. Instead, counselors learn this “on the job”; we do our best to educate ourselves and to grow based on our experiences.

Those of us who have a special interest in working with this population seek additional training to acquire competence and to keep up with research in the field. Ongoing program evaluation at treatment sites is crucial so that we remain responsible for the outcome of our work and, at the same time, accountable to the public and to the third-party payers. We must constantly ask ourselves: Does what I do make a difference? Is my approach effective?”

The more common experience counselors have working with sexual assault survivors is in the traditional therapy setting, whether one-on-one or in groups, on campuses or within specialized agencies. Working with sexual assault survivors can be long and complicated, but it is often a rewarding journey of healing. Each of us tailors our own theoretical approach and framework to the needs of survivors with the techniques our profession has awarded us. So, we tend to approach sexual assault response from this end, engaging in short- or long-term therapy with survivors at some point on their journeys to heal.

Crisis intervention

An additional way to respond to sexual assault is at its onset, from a crisis intervention perspective. Traditionally, this is where victim advocates come in. Most counselors are not victim advocates, and most victim advocates are not counselors. Likewise, not all sexual assault survivors seek out victim advocate services, especially if they are already in counseling for other things. Regardless, counselors are often on the front lines of sexual assault reports and can be better prepared to handle such situations if they properly equip themselves.

To provide an adequate, timely and holistic response to sexual assault, it is essential that we learn about victim advocacy and incorporate some critical elements of this training into our counseling work when appropriate. Given the lack of specialized preparation during counseling training, I believe that counselors clearly need more tools to help them better respond to sexual assault, and I believe a need exists for an interdisciplinary approach regarding education, prevention and response efforts.

Based on the statistics, at some point during our practice as counselors, we will all encounter a client who reports sexual assault. I have worked in two campus-based counseling centers, and the number of students who reported sexual assault was startlingly high. According to 2016 statistics from the Rape, Abuse & Incest National Network (RAINN), young adults between the ages of 18 and 24 are at an elevated risk of sexual violence. In addition, based on statistics from the Centers for Disease Control and Prevention’s National Intimate Partner and Sexual Violence Survey published in 2011, it is estimated that 1.3 million women were raped in the past 12 months in the U.S. What I have learned over the course of the past 11 years in practice — as well as from my clients, students and colleagues — is that we, as counselors, need stronger training for providing a more timely and appropriate response to sexual assault.

In attempting to provide additional resources for my students who want to specialize in sexual assault response, I have found that the availability of trainings and educational programs varies widely from state to state. Information on these services and resources is scattered. We need to create education, training and workshops for those who want to specialize in this work. Perhaps what is called for is a nationwide network in which training and specialty certifications are streamlined and accessible in every state.

Meanwhile, I have attempted to put together a user-friendly diagram for counselors working with sexual assault survivors. In the remainder of this article, I will present a model that may help to organize sexual assault response into groupings for individuals who want to easily locate the appropriate next steps after a sexual assault or rape report. Allowing the survivor to have a voice and a choice in what comes next should serve as the most significant guiding element for counselors.

 

A chart of required or recommended action steps to take immediately after a report of sexual assault (courtesy of Hasmik Chakaryan).

 

Response to assault based on immediacy

One important recommendation is to always consider how the individual refers to herself (or himself) before using terms such as “victim” or “survivor.” The chart above walks readers through the required or recommended action steps immediately after a sexual assault report.

First, assess for safety. When working with victims of crime, it is critical to always consider their immediate needs first. It would be challenging and potentially damaging to the client to process any emotional responses without first addressing the physical or physiological needs, much like Abraham Maslow’s hierarchy directed.

Second, evaluate psychological needs. What are the individual’s most pressing psychological needs? This is where counselors apply their attending skills and provide the individual with empathy and respect.

From the tens of thousands of unprocessed rape kits (per a 2015 article in USA Today) to recent public rulings reducing sentences for college assaults (CNN, 2016) to new proposed laws that would permit a rapist parental rights (CNN, 2016), it appears that our society sometimes is confused about who the victim is and often participates in victim blaming. This widespread phenomenon often affects the ability of victims to recognize their experiences as assault and themselves as victims. It is imperative that counselors work against these societal/cultural norms by first questioning their own views.

Professionals need to check their assumptions and biases regarding sexual assault and who the victim is prior to sitting down with these individuals face-to-face. Counselors must become outspoken advocates for this population and ensure that the best psychological services are provided for survivors of this crime. This requires us to be nonjudgmental and to assert that a sexual assault is never the survivor’s fault. We should include assurances that the survivor is not responsible for either the crime or for the direct effects of that crime.

Third, lay out legal options. Does the survivor want to report the assault? Counselors do not provide legal counsel, but they do need to be informed about certain key elements when working with survivors who discuss legal actions. Most important, never make these individuals feel pressured to report; always allow them to make their own informed decisions.

If survivors decide that they do want to report the crime, inform them of the following:

  • Pursuing legal action requires collaboration with legal services, local police and forensic services. It is vital to process crime scenes immediately while there is still viable evidence and a better chance of locating witnesses to interview for accurate findings.
  • In some states, individuals can access treatment and counseling free of charge when they report the assault.
  • Reporting the assault can be empowering for some survivors and can help them regain some sense of agency. Reporting does not, however, guarantee that the perpetrator will be prosecuted. It is vital to avoid giving survivors false hope and expectations. In fact, a very small percentage of reported sexual assaults end up with the arrest of the perpetrator. According to a 2016 CNN report, of the nearly 300,000 average annual rape and sexual assault victimizations between 2005 and 2010, only about 12 percent resulted in arrests. Such statistics shouldn’t be shared to discourage individuals from pursuing legal actions. Rather, it is critical to process the expectations of sexual assault survivors in counseling.

Forensic exams

It is important to clarify the role of the forensic examiner (or the sexual assault nurse examiner) to sexual assault survivors. These medical professionals are very different from the nurses one might associate with a hospital emergency room. Instead, they are fulfilling a criminal justice role during the sexual assault exam, which is essentially a procedure to collect evidence. It is also imperative to explain the purpose of this forensic exam, the time sensitivity, the statute of limitations and the costs associated with the exam.

If survivors decide to pursue a forensic exam, notify them that they can terminate the exam at any time and can ask for a victim advocate or anyone else they want to be with them in the room. In most states, survivors of sexual assault incur no cost for the exam. The cost depends on what is included in the exam, what lab work and testing are performed, whether testing and prevention of sexually transmitted diseases are completed and whether any injuries incurred during the assault are treated. It is important to check any laws that may hinder the process in any way so that no unrealistic promises are made to survivors.

Counselors working with sexual assault survivors should know that many states process sexual assault forensic exams and related services under the Violence Against Women Act. One valuable resource for professionals and survivors is the RAINN website (rainn.org/articles/rape-kit), which offers a detailed rundown of what happens during the forensic exam. This information helps individuals grasp the importance of the forensic exam for evidence collection and assists them in making informed decisions. For all these reasons and more, independent advocacy is crucial for sexual assault survivors during the exam and throughout the entire process.

Immediate vs. delayed reporting

Providing survivors with information regarding the pros and cons of immediate versus delayed reporting can help them make educated decisions and aid the reporting process. Most of the information that follows in this section on the important elements of reporting and what reporting entails is based on the work of Andrea Sundberg and Dorene Whitworth at the Nevada Coalition Against Sexual Violence.

When a survivor of sexual assault arrives at the emergency room, the police are notified. Officers will interview the survivor for a thorough account of the assault. This helps them collect all of the crucial details while the person’s memory is fresh, giving them a better chance of collecting evidence to aid the legal process.

Providing a report of the assault to police is not the same thing as pressing charges against the perpetrator. Those are separate processes. It is vital for counselors to talk about this with sexual assault survivors and to prepare them as best they can. Not all police officers are trained to work with sexual assault survivors, and this interview may be triggering for these individuals.

Survivors may also choose to delay the reporting until they feel better prepared to handle it emotionally. The potential consequences of delayed reporting can include additional hurdles for thorough investigation, a lack of witnesses and a fading of the person’s memory regarding details of the assault. Delayed reporting may also affect the perceptions and responses of prosecutors and jurors and influence the prosecutor’s ability to obtain a conviction.

No report to law enforcement

Counselors working with sexual assault survivors may assume that the best direction for survivors to take is to immediately report the crime. There are many reasons why survivors may not want to report to law enforcement, however.

Most individuals hesitate to report immediately when there is fear of further danger to self, family or others. Others hesitate to report because of cultural beliefs or because of financial dependence on the perpetrator. Some individuals fear the investigation might reveal some kind of illegal activity related to underage drinking, prostitution, immigration status or other issues. Other individuals are simply terrified at the prospect of facing their perpetrators.

Some survivors will not report to law enforcement because of a sense of shame or embarrassment or because they worry about being blamed for the assault. There are also survivors who do not want to get their perpetrators in trouble because they are family members or are current or former intimate partners of the survivor. Some individuals may fear retaliation, especially if the perpetrator is their superior, employer or supervisor. If the perpetrator is a popular figure, survivors may fear social condemnation and disbelief if they report. Some survivors may lack trust in, or have had a prior negative experience with, law enforcement or the criminal justice system.

After obtaining 40 hours of intensive training in sexual assault response, I volunteered as a victim advocate, providing resources over a crisis hotline to individuals in central Ohio. Often, I would get calls from women saying they had been sexually assaulted by someone involved in law enforcement or the criminal justice system. These women feared more severe consequences if they chose to report. In some cases, these perpetrators were the survivors’ past or current partners; in other cases, they were not related to the survivor at all. In one particular case, the survivor told me over the phone that she feared going to the emergency room because the same police officer who had sexually assaulted her might respond to the call while he was on duty.

Regardless of whether individuals choose to report an assault, a forensic exam is available to them. The Violence Against Women Reauthorization Act of 2013 made it easier for all survivors to obtain a “Jane Doe rape kit,” through which they are given a code to identify themselves should they choose to report at a later date. Under this regulation, survivors must be offered a forensic exam and reimbursement for the cost of the exam without being required to participate in the criminal justice system or cooperate with law enforcement. This applies to all states in their applications for STOP Violence Against Women Formula Grants. In addition, survivors are not required to use their insurance benefits to pay for the forensic exams, which can offer them extra protection.

When educating sexual assault survivors about all of the possible options, it is critical not to make any promises that cannot subsequently be fulfilled. It is important to first find out how specific jurisdictions work and what procedures they follow. It is also imperative that counselors not pressure a survivor into any of these steps or decisions just because the counselor thinks it might be the best option. These individuals were already stripped of their choice and autonomy when they were coerced into nonconsensual sex, so it is vital that this agency be given back to them as part of the process that follows.

It is also important for counselors to know that sexual assault survivors are not limited to only one type of reporting. Indeed, there are various kinds of reporting, including:

  • No law enforcement involvement
  • Law enforcement involvement, storage only
  • Law enforcement involvement, anonymous/blind report (blind reporting is not the same as a third-party report; blind reporting means that the victim is involved but not identified)

For additional details on each of these options, refer to usmc-mccs.org/articles/restricted-vs-unrestricted-reports-know-your-options/.

Student/supervisee disclosure

When disclosure of a sexual assault is made by a student or supervisee, it is crucial to be trained in your institution’s Title IX regulations and requirements to respond adequately. The response will also depend on whether the individual is considered under the age of consent in your state.

I usually immediately connect students or supervisees with an on-campus victim advocate who then walks them through the entire process. I offer my expertise and answer their questions and concerns to ease some of their fears before referring them. If they request that I make the initial contact with the victim advocate and help facilitate the meeting, I offer to go to the first meeting with them.

The process of disclosing a sexual assault and deciding whether to report it understandably provokes anxiety in survivors. They are dealing with multiple effects that may include physical, psychological, spiritual and other issues. The most important piece for me is to make sure that I am present, available, attentive, caring, empathetic, responsive and nonjudgmental, and that I am able to provide a safe place for the survivor. I recommend that we all frequently assess our assumptions and biases regarding sexual assault and who the victims are because these are the nuances that can erect barriers between us and sexual assault survivors.

For more information about campus sexual assault prevention and services, see the White House Task Force to Protect Students from Sexual Assault 2014 fact sheet at justice.gov/ovw/page/file/910266/download.

Other considerations

Short-term crisis intervention vs. long-term counseling: Short-term services for sexual assault survivors include the initial crisis response and intervention immediately following the assault. Long-term mental health services might include a variety of therapeutic components such as assessments, goal setting, treatment planning and step-by-step work through each mental health concern and progress toward therapeutic goals.

A 2014 White House task force study of a community sample of rape survivors found that survivor outcomes were better in communities that had a greater number of post-assault resources. This also means that survivors report better outcomes when short-term crisis intervention is followed by long-term services such as a combination of individual counseling and group support work. Sometimes, it also may be beneficial to involve the family in the therapeutic process.

Trauma-informed care for treating sexual assault survivors: Trauma-informed care is a service delivery framework that considers the unique needs of trauma survivors by treatment providers. As part of this approach, important questions, such as how survivors should be treated by clinicians and what clinicians should be aware of when they are the first contact for mental health treatment, are addressed. Trauma-informed care simply adds a context of trauma to whatever theoretical approach and techniques clinicians find appropriate to use in their work with sexual assault survivors. It also brings up critical elements of neuroscience as a background to our clients’ trauma experiences.

Culturally competent counseling: Trauma looks different depending on the culture. In some cultures, women are blamed for being sexually assaulted. They are subsequently stigmatized, isolated and labeled as “damaged goods,” often resulting in them remaining alone for the rest of their lives. In other cultures, laws allow perpetrators of sexual assault to walk free while victims are either banned from the community or suffer severe punishments such as hanging or stoning.

To work effectively with sexual assault survivors in either short-term or long-term settings, it is imperative for counselors to possess strong contextual knowledge of the individual’s cultural, religious and ethnic backgrounds. Such knowledge helps us understand intricate nuances regarding the survivor’s self-perception, self-worth and perception of sexual acts, including those that were not consensual. It also allows for a more open conversation in a safe and nonjudgmental environment so that counselors can better guide survivors through their unique circumstance.

It is our ethical responsibility as counselors to continuously seek more education, awareness and self-growth in relation to culturally responsible and evidence-based counseling services.

Sexaual assault response training for counselors who desire to specialize: In most states, various sexual assault response teams carry out victim advocate trainings. These trainings are typically 40-hour, intensive educational experiences that include interdisciplinary input from experts in various specialty areas. Counselors who are not equipped to work with sexual assault survivors can always find a victim advocate to refer to in the area.

For more information on locating victim advocates in your area, see the National Organization for Victim Assistance website at trynova.org/crime-victim/advocacy/list/.

For more information on victim advocate roles and trainings, see the National Center for Victims of Crime website at victimsofcrime.org/help-for-crime-victims/get-help-bulletins-for-crime-victims/what-is-a-victim-advocate-.

For hotlines and other helpful links from the National Center for Victims of Crime, see victimsofcrime.org/help-for-crime-victims/national-hotlines-and-helpful-links.

 

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Hasmik Chakaryan is an assistant professor and director of clinical programs in the Department of Professional Counseling at Webster University. In addition, she is a licensed professional counselor, a clinical supervisor, a victim advocate and a trauma specialist. Her research also focuses on internationalizing the profession of counseling. Contact her at hchakaryan06@webster.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.