Tag Archives: sexual abuse

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.

Understanding and treating survivors of incest

By David M. Lawson March 6, 2018

Adults with histories of being abused as children present unique challenges for counselors. For instance, these clients often struggle with establishing and maintaining a therapeutic alliance. They may rapidly shift their notion of the counselor from very favorable to very unfavorable in line with concomitant shifts in their emotional states. Furthermore, they may anxiously expect the counselor to abandon them and thus increase pressure on the counselor to prove otherwise. Ironically, attempts at reassurance by the counselor may actually serve to validate these clients’ fears of abandonment.

The motivating factor for many of these clients is mistrust of people in general — and often for good reason. This article explores the psychological and interpersonal aspect of child sexual abuse by a parent and its treatment, with a particular focus on its relationship to betrayal trauma, dissociation and complex trauma.

Incest and its effects

Child abuse of any kind by a parent is a particularly negative experience that often affects survivors to varying degrees throughout their lives. However, child sexual abuse committed by a parent or other relative — that is, incest — is associated with particularly severe psychological symptoms and physical injuries for many survivors. For example, survivors of father-daughter incest are more likely to report feeling depressed, damaged and psychologically injured than are survivors of other types of child abuse. They are also more likely to report being estranged from one or both parents and having been shamed by others when they tried to share their experience. Additional symptoms include low self-esteem, self-loathing, somatization, low self-efficacy, pervasive interpersonal difficulties and feelings of contamination, worthlessness, shame and helplessness.

One particularly damaging result of incest is trauma bonding, in which survivors incorporate the aberrant views of their abusers about the incestuous relationship. As a result, victims frequently associate the abuse with a distorted form of caring and affection that later negatively influences their choice of romantic relationships. This can often lead to entering a series of abusive relationships.

According to Christine Courtois (Healing the Incest Wound: Adult Survivors in Therapy) and Richard Kluft (“Ramifications of incest” in Psychiatric Times), greater symptom severity for incest survivors is associated with:

  • Longer duration of abuse
  • Frequent abuse episodes
  • Penetration
  • High degree of force, coercion and intimidation
  • Transgenerational incest
  • A male perpetrator
  • Closeness of the relationship
  • Passive or willing participation
  • Having an erotic response
  • Self-blame and shame
  • Observed or reported incest that continues
  • Parental blame and negative judgment
  • Failed institutional responses: shaming, blaming, ineffectual effort
  • Early childhood onset

Incest that begins at a young age and continues for protracted periods — the average length of incest abuse is four years — often results in avoidance-based coping skills (for example, avoidance of relationships and various dissociative phenomena). These trauma-forged coping skills form the foundation for present and future interpersonal interactions and often become first-line responses to all or most levels of distress-producing circumstances.

More than any other type of child abuse, incest is associated with secrecy, betrayal, powerlessness, guilt, conflicted loyalty, fear of reprisal and self-blame/shame. It is of little surprise then that only 30 percent of incest cases are reported by survivors. The most reliable research suggests that 1 in 20 families with a female child have histories of father-daughter child sexual abuse, whereas 1 in 7 blended families with a female child have experienced stepfather-stepdaughter child sexual abuse (see the revised edition of The Secret Trauma: Incest in the Lives of Girls and Women by Diana E. H. Russell, published in 1999).

In 1986, David Finkelhor, known for his work on child sexual abuse, indicated that among males who reported being sexually abused as children, 3 percent reported mother-son incest. However, most incest-related research has focused on father-daughter or stepfather-stepdaughter incest, which is the focus of this article.

Subsequent studies of incest survivors indicated that being eroticized early in life disrupted these individuals’ adult sexuality. In comparison with nonincest controls, survivors experienced sexual intercourse earlier, had more sex partners, were more likely to have casual sex with those outside of their primary relationships and were more likely to engage in sex for money. Thus, survivors of incest are at an increased risk for revictimization, often without a conscious realization that they are being abused. This issue often creates confusion for survivors because the line between involuntary and voluntary participation in sexual behavior is blurred.

An article by Sandra Stroebel and colleagues, published in 2013 in Sexual Abuse: A Journal of Research and Treatment, indicates that risk factors for father-daughter incest include the following:

  • Exposure to parent verbal or physical violence
  • Families that accept father-daughter nudity
  • Families in which the mother never kisses or hugs her daughter (overt maternal affection was identified as a protective factor against father-daughter incest)
  • Families with an adult male other than the biological father in the home (i.e., a stepfather or substitute father figure)

Finally, some qualitative research notes that in limited cases, mothers with histories of being sexually abused as a child wittingly or unwittingly contribute to the causal chain of events leading to father-daughter incest. Furthermore, in cases in which a mother chooses the abuser over her daughter, the abandonment by the mother may have a greater negative impact on her daughter than did the abuse itself. This rejection not only reinforces the victim’s sense of worthlessness and shame but also suggests to her that she somehow “deserved” the abuse. As a result, revictimization often becomes the rule rather than the exception, a self-fulfilling prophecy that validates the victim’s sense of core unworthiness.

Beyond the physical and psychological harm caused by father-daughter incest, Courtois notes that the resulting family dynamics are characterized by:

  • Parent conflict
  • Contradicting messages
  • Triangulation (for example, parents aligned against the child or perpetrator parent-child alignment against the other parent)
  • Improper parent-child alliances within an atmosphere of denial and secrecy

Furthermore, victims are less likely to receive support and protection due to family denial and loyalty than if the abuser were outside the family or a stranger. Together, these circumstances often create for survivors a distorted sense of self and distorted relationships with self and others. If the incest begins at an early age, survivors often develop an inherent sense of mistrust and danger that pervades and mediates their perceptions of relationships and the world as a whole.

Betrayal trauma theory

Betrayal trauma theory is often associated with incest. Psychologist Jennifer Freyd introduced the concept to explain the effects of trauma perpetrated by someone on whom a child depends. Freyd holds that betrayal trauma is more psychologically harmful than trauma committed or caused by a noncaregiver. “Betrayal trauma theory posits that under certain conditions, betrayals necessitate a ‘betrayal blindness’ in which the betrayed person does not have conscious awareness or memory of the betrayal,” Freyd wrote in her book Betrayal Trauma: The Logic of Forgetting Childhood Abuse.

Betrayal trauma theory is based on attachment theory and is consistent with the view that it is adaptive to block from awareness most or all information about abuse (particularly incest) committed by a caregiver. Otherwise, total awareness of the abuse would acknowledge betrayal information that could endanger the attachment relationship. This “betrayal blindness” can be viewed as an evolutionary and nonpathological adaptive reaction to a threat to the attachment relationship with the abuser that thus explains the underlying dissociative amnesia in survivors of incest. Under these circumstances, survivors often are unaware that they are being abused, or they will justify or even blame themselves for the abuse. In severe cases, victims often have little or no memory of the abuse or complete betrayal blindness. Under such conditions, dissociation is functional for the victim, at least for a time.

Consider the case of “Ann,” who had been repeatedly and severely physically and sexually abused by her father from ages 4 to 16. As an adult, Ann had little to no memory of the abuse. As a result of the abuse, she had developed nine alternate identities, two of which contained vivid memories of the sexual and physical abuse. Through counseling, she was able to gain awareness of and access to all nine alternate identities and their functions.

Although Ann expressed revulsion and anger toward her father, she also expressed her love for him. At times, she would lapse into moments of regret for disclosing the abuse, saying that “it wasn’t so bad” and that the worst thing that had happened was that she had lost her “daddy.” During these moments, Ann minimized the severity of the abuse, wishing that she had kept the incest secret so that she could still have a relationship with her father. This was an intermittent longing for Ann that occurred throughout counseling and beyond.

Thus, understanding attachment concepts is critical for understanding betrayal traumas such as incest. Otherwise, counselors might be inclined to blame survivors or might feel confused and even repulsed by survivors’ behaviors and intentions. For many survivors, the caregiver-abuser represents the best and the worst of her life at various times. She needs empathy and support, not blame.

Dissociation

As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, dissociation is “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, perception, body representation, motor control and behavior.” Depending on the severity of the abuse, dissociative experiences can interfere with psychological functioning across the board. Survivors of incest often experience some of the most severe types of dissociation, such as dissociative identity disorder and dissociative amnesia (the inability to recall autobiographical information). Dissociative experiences often are triggered by perceived threat at a conscious or unconscious level.

As previously noted, betrayal trauma theory holds that for incest survivors, dissociative amnesia serves to maintain connection with an attachment figure by excluding knowledge of the abuse (betrayal blindness). This in turn reduces or eliminates anxiety about the abuse, at least in the short run. Conversely, many survivors of childhood incest report continuous memories of the abuse, as well as the anxiety and felt terror related to the abuse. Often, these individuals will find a way to leave their homes and abusers. This is less frequently the case for survivors who experience dissociative amnesia or dissociative identity disorder.

Depersonalization and derealization distort the individual’s sense of self and her sensory input of the environment through the five senses. For example, clients who have experienced incest often report that their external world, including people, shapes, sizes, colors and intensities of these perceptions, can change quickly and dramatically at times. Furthermore, they may report that they do not recognize themselves in a mirror, causing them to mistrust their own perceptions.

As one 31-year-old incest survivor stated, “For so many years, everything within me and around me felt and looked unreal, dull, dreary, fragmented, distant.” This is an example of depersonalization/derealization. She continued, “This, along with the memory gaps, forgetfulness and inability to recall simple everyday how-tos, like how to drive a car or remember the step-by-step process of getting ready for the day, made me feel crazy. But as I improved in counseling, my perceptions of my inside and outside worlds became clearer, more stable, and brighter and more distinct than before counseling. It all came to make more sense and feel right. It took me years to see the world as I think other people see it. From time to time I still experience that disconnection and confusion, but so much less frequently now than before.”

Initially, some real or perceived threat triggers these distorted perceptions of self and outer reality, but eventually they become a preset manner of perceiving the world. Reports such as this one are not uncommon for survivors of incest and often are exacerbated as these individuals work through the process of remembering and integrating trauma experiences into a coherent life narrative. For many survivors, a sense of coherence and stability is largely a new experience; for some, it can be threatening and trigger additional dissociative experiences. The saying “better a familiar devil than an unfamiliar angel” seems to apply here.

The severity of dissociation for survivors of incest is related to age onset of trauma exposure and a dose-response association, with earlier onset, more types of abuse and greater frequency of abuse associated with more severe impairment across the life span. Incest is associated with the most severe forms of dissociative symptoms such as dissociative identity disorder. Approximately 95 to 97 percent of individuals with dissociative identity disorder report experiencing severe childhood sexual and physical abuse.

Fragmentation in one’s sense of self, accompanied by amnesia of abuse memories, is particularly functional when children cannot escape the abuse circumstances. These children are not “present” during the abuse, so they often are not aware of the physical and emotional pain associated with the abuse. Yet this fragmented sense of self contributes to a sense of emptiness and absence, memory problems and dissociative self-states. Many survivors of incest are able to “forget” about the abuse until sometime later in adulthood when memories are triggered by certain events or when the body and mind are no longer able to conceal the memories. The latter results from the cumulative effect of lifelong struggles related to the incest (for example, interpersonal problems and emotional dysregulation). It takes a great deal of psychological and physical resources to “forget” trauma memories.

Dissociation, especially if it involves ongoing changes in perceptions of self and others, different presentations of self and memory problems, may result in difficulty forming and maintaining a therapeutic alliance. Dissociation disrupts the connection between the client and the counselor. It also disrupts clients’ connections with their inner experience. If these clients do not perceive themselves and their surroundings as stable, they will mistrust not only their counselors but also their own perceptions, which create ongoing confusion.

Thus, counselors must remain alert to subtle or dramatic fluctuations in survivors’ presentation styles, such as changes in eye contact or shifts in facial features from more engaged and animated to flat facial features. Changes in voice tone quality and cadence (from verbally engaged to silent) or in body posture (open versus closed) are other signs of possible dissociative phenomena. Of course, all or none of these changes may be indicators of dissociative phenomena.

Complex trauma

Incest, betrayal trauma and dissociative disorders are often features of a larger diagnostic categorization — complex trauma. Incest survivors rarely experience a single incident of sexual abuse or only sexual abuse. It is more likely that they experience chronic, multiple types of abuse, including sexual, physical, emotional and psychological, within the caregiving system by adults who are expected to provide security and nurturance.

Currently, an official diagnostic category for complex trauma does not exist, but one is expected to be added to the revised International Classification of Diseases (ICD-11) that is currently in development. Marylene Cloitre, a member of the World Health Organization ICD-11 stress and trauma disorders working group, notes that the new complex trauma diagnosis focuses on problems in self-organization resulting from repeated/chronic exposure to traumatic stressors from which one cannot escape, including childhood abuse and domestic violence. Among the criteria she highlighted for complex trauma are:

  • Disturbances in emotions: Affect dysregulation, heightened emotional reactivity, violent outbursts, impulsive and reckless behavior, and dissociation.
  • Disturbances in self: Defeated/diminished self, marked by feeling diminished, defeated and worthless and having feelings of shame, guilt or despair (extends despair).
  • Disturbances in relationships: Interpersonal problems marked by difficulties in feeling close to others and having little interest in relationships or social engagement more generally.
    There may be occasional relationships, but the person has great difficulty maintaining them.

Early onset of incest along with chronic exposure to complex trauma contexts interrupts typical neurological development, often leading to a shift from learning brain (prefrontal cortex) to survival brain (brainstem) functioning. As explained by Christine Courtois and Julian Ford, survivors experience greater activation of the primitive brain, resulting in a survival mode rather than activation of brain structures that function to make complex adjustments to the current environment. As a result, survivors often exhibit an inclination toward threat avoidance rather than being curious and open to experiences. Complex trauma undermines survivors’ ability to fully integrate sensory, emotional and cognitive data into an organized, coherent whole. This lack of a consistent and coherent sense of self and one’s surroundings can create a near ever-present sense of confusion and disconnection from self and others.

Regular or intermittent complex trauma exposure creates an almost continual state of anxiety and hypervigilance and the intrinsic expectation of danger. Incest survivors are at an increased risk for multiple impairments, revictimization and loss of support.

Treatment issues

Although a comprehensive description of treatment is well beyond the scope of this article, I will close with a general overview of treatment concepts. Treatment for incest parallels the treatment approaches for complex trauma, which emphasizes symptom reduction, development of self-capacities (emotional regulation, interpersonal relatedness and identity), trauma processing and the addressing of dissociative experiences.

Compromised self-capacities intensify symptom severity and chronicity. Among these self-capacities, emotional dysregulation is a major symptom cluster that affects other self-capacity components. For example, if a survivor consistently struggles with low frustration tolerance for people and copes by avoiding people, responding defensively, responding in a placating manner or dissociating, she likely will not have the opportunity to develop fulfilling relationships. The following core concepts, published in the May 2005 Psychiatric Annals, were suggested by Alexandra Cook and colleagues for consideration when implementing a treatment regimen for complex trauma, including with incest survivors and with adaptations for clients with dissociative identity disorder.

1) Safety: Develop internal and environmental safety procedures.

2) Self-regulation: Enhance the capacity to moderate and rebalance arousal across the areas of affective state, behavior, physiology, cognition, interpersonal relatedness and self-attribution.

3) Self-reflective information processing: Develop the ability to focus attentional processes and executive functioning on the construction of coherent self-narratives, reflecting on past and present experience, anticipation and planning, and decision-making.

4) Traumatic experiences integration: Engage in resolution and integration of traumatic memories and associated symptoms through meaning making, traumatic memory processing, remembrance and mourning of traumatic loss, development of coping skills, and fostering present-oriented thinking and behavior.

5) Relational engagement: Repair, restore or create effective working models of attachment and application of these models to current interpersonal relationships, including the therapeutic alliance. Emphasis should be placed on development of interpersonal skills such as assertiveness, cooperation, perspective taking, boundary and limit setting, reciprocity, social empathy and the capacity for physical and emotional intimacy.

6) Positive affect enhancement: Work on the enhancement of self-worth, self-esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery seeking, community building and the capacity to experience pleasure.

Typically, these components are delivered within a three-phase model of counseling that is relationship-based, cognitive behavioral in nature and trauma focused:

  • Safety, self-regulation skill development and alliance formation
  • Trauma processing
  • Consolidation

The relational engagement component is particularly critical because for many survivors, to be attached often has meant to be abused. Furthermore, accompanying feelings of shame, self-loathing and fear of abandonment create a “failure identity” that results in low expectations for change. Additionally, it is important for counselors to attend to client transference issues and counselor countertransference issues. Courtois suggests that ignoring or assuming that such processes are irrelevant to the treatment of survivors can undermine the treatment process and outcome.

In addition, strength-based interventions are critical in each phase to help survivors develop a sense of self-efficacy and self-appreciation for the resources they already possess. A strength-based focus also contributes to client resilience.

For some clients, dissociated self-states or parts will emerge. Counselors should assume that whatever is said to one part will also be heard by the other parts. Therefore, addressing issues in a manner that encourages conversation between parts, including the core self-structure, is critical. It is also important to help parts problem-solve together and support each other. This is not always an easy proposition. A long-term goal would be some form of integration/fusion or accord among alternate identities. Some survivors eventually experience full unification of parts, whereas others achieve a workable form of integration without ever fully unifying all of their alternate identities (for more, see Treating Trauma-Related Dissociation: A Practical, Integrative Approach by Kathy Steele, Suzette Boon and Onno van der Hart).

Finally, it must be mentioned that repeated exposure to horrific stories of incest can overwhelm counselors’ capacity to maintain a balanced relationship with clear boundaries. A client’s transference can push the boundaries of an ethical and therapeutic client-counselor relationship. Furthermore, the frequent push-pull dynamics between counselor and client can be exhausting, both physically and mentally for counselors. Therefore, it is important for counselors to frequently seek supervision and consultation and to engage in self-care physically, psychologically and spiritually.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences

David M. Lawson is a professor of counselor education and director of the Center for Research and Clinical Training in Trauma at Sam Houston State University. His research focuses on childhood sexual and physical abuse, complex trauma and dissociation related to trauma. He also maintains an independent practice focusing on survivors of posttraumatic stress disorder and complex trauma. Contact him at dml3466@aol.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.

 

Counseling survivors of human trafficking

By Lamerial McRae and Letitia Browne-James October 9, 2017

Millions of human trafficking victims exist across the globe. In the United States, hundreds of thousands of victims experience trafficking. As society expands and evolves, human trafficking perpetrators find new ways to recruit and victimize others. The evolution of perpetration ensues because of increases in accessing technology, shifting state and federal laws, and changing criminal investigation methods within communities. Human trafficking continues to evolve into a new way of enslaving human beings, stripping individuals of basic rights and freedoms, while skirting the legal issues of slavery and ownership.

Human traffickers often recruit individuals by offering the fantasy of increased happiness, stability, relationship success and financial freedom. Human traffickers, often referred to as “pimps” or “playboys,” may recruit a female or male victim with promises of a better quality of life, including, but not limited to money, security and safe shelter. These perpetrators often present as charming and recruit their victims using lies and manipulation. They prey on victims from vulnerable populations, including those with low socioeconomic status (SES), biological females, children and adolescents, immigrants and LGBTQ+ youth. The fact that these vulnerable populations often remain dependent on others or experience institutionalized marginalization allows for perpetrators to paint the picture of a better life, both in terms of finance and social support. Thus, counselors must understand the cycle of perpetration and victimization to pinpoint potential victims among clients.

As a starting point, counselors must understand the nature of the phenomenon and seek ways to identify potential risk and protective factors. Counselors must learn to assess and address possible victimization with effective rapport building and intervention. For example, youth may display delinquent behavior (e.g., truancy, sexual misconduct, drug use) as a symptom of coercion and threats by a perpetrator. Perpetrators often experience greater ease when recruiting teenagers because of their tendency to be influenced by others. Sadly, when teenagers fall victim to a human trafficker, they are subjected to the victim-blaming phenomenon.

Thus, to build therapeutic rapport from a nonjudgmental framework, counselors need to understand the true source of teenagers’ behavior rather than labeling them as inappropriate or delinquent. As counselors increase their understanding of risk and protective factors, the profession may be able to conceptualize human trafficking as a systemic problem from a broad perspective.

 

Risk and protective factors

Several risk and protective factors exist for those falling victim to human trafficking. Risk factors include the following demographics and experiences. Risk factors, which are not limited to the list provided, may change over time with the help of counselors.

  • Low SES
  • Previous or current substance abuse
  • Social vulnerability (e.g., children, females, LGBTQ+ individuals)
  • Limited education.

Protective factors, referred to as strengths in counseling, include the following demographics and experiences. Counselors must foster protective factors and strengths in clients to reduce the risk of falling victim to trafficking.

  • Education
  • Family stability
  • Strong social support networks
  • Mental and emotional health

Counselors should understand these risk and protective factors to assess potential risks for human trafficking and to focus on increasing protective factors in counseling. For example, counselors may use a family counseling approach when working with survivors to increase their connections to loved ones and family. Throughout the process of recruiting and selling human trafficking victims, counselors may notice several risk and protective factors playing a role in the process.

 

Human trafficking business model and counseling implications

Human trafficking remains a mysterious and misunderstood phenomenon. Because of a lack of understanding about the effects of human trafficking on our society, counselors are charged with educating themselves to best address and assess individuals for victimization.

Counselors should recognize that survivors of sex trafficking require additional techniques (to those used with other clients) to build rapport with them and to reduce the mistrust that they commonly have about people. To best serve survivors, treatment approaches need to remain centered on survivors, empower them, provide safety and involve a multidisciplinary approach. In addition, professional counselors working extensively with sex trafficking survivors hold legal and ethical responsibilities to provide appropriate services and identify strategies to overcome barriers to their treatment, including specialized and intensive training.

To begin, counselors must understand the human trafficking business model to conceptualize the systemic issue and the moving parts that contribute to the continuing cycle. To highlight some of the societal and professional impacts, consider the parallel of the human trafficking business model to the process of manufacturing goods. The human trafficking business model includes the following stages of grooming and distribution:

1) The supplier recruits the victim.

2) The manufacturer grooms the victim.

3) The retailer determines price and then markets the victim.

4) The retailer sells and the consumer purchases the victim.

The human trafficking business model is a sophisticated process, not always linear in nature, and it functions as a well-established industry. Thus, the need exists to explore each of the model to better understand how to help victims and break the cycle.

Stage 1: Supplying victims. The supplier, also known as the initial human trafficking perpetrator, displays high levels of mental health concerns (e.g., antisocial personality traits) and shows little concern for the basic human rights of others. When victims enter this stage, counselors may find that these individuals report troubles at home, low SES, depression, anxiety and truant behavior. These factors contribute to their need to survive. Unfortunately, this may result in a perpetrator using charm or manipulation to attract the victims. Perpetrators remove victims’ identification, passports and other valuables to trap them in the world of human trafficking.

Clinical assessment is vital at this stage and remains an ongoing process. Counselors may want to ease survivors into telling their stories, paying special attention to the therapeutic relationship. Thus, the most valuable interventions at this stage include active listening and reflection. When administering specific assessment instruments, counselors will want to measure attitudes about victimization and perpetration and prevalence rates of violence. Counselors must use both open- and closed-ended questions to directly address potential victimization. Nonverbally, counselors will want to avoid direct eye contact and limit their use of touch because of victims’ trauma and abuse history.

Stage 2: Grooming victims. This stage involves moving human trafficking victims from the supplier to the manufacturer. Perpetrators continue to display high levels of antisocial behaviors and major mental health concerns; survivors present with mental health concerns such as depression, anxiety and addiction. Substance abuse concerns usually present when perpetrators force their victims to engage in substance use to coerce and control their behaviors, often resulting in addiction.

Counselors must use clinical assessment and maintain that ongoing process. In addition, because survivors have been manufactured as a human trafficking product, their levels of abuse and mistrust often appear high when they present to counseling. Therefore, counselors must focus on the therapeutic relationship as victims provide information about their experiences in trafficking. Counselors should pay special attention to reducing the stigma of substance use and mental health concerns, especially considering that victims develop these concerns because of coercion and violence.

Stage 3: Marketing victims. This stage involves moving survivors from the manufacturer to the retailer. At this stage, human trafficking perpetrators focus on the marketing and sales aspect of their exploitation. For example, based on the quality of their goods (i.e., victim age, appearance) and market demand, perpetrators determine the price for selling each of their victims. At this stage, survivors present with major depressive, dissociative and addiction disorders.

At this stage, counselors again use clinical assessment to understand the survivor’s story while maintaining a trustworthy therapeutic relationship. As previously stated, severe mental health concerns present because of the violence and abuse that victims experience. Thus, counselors need to use evidenced-based practices to treat depression and dissociative symptoms. Some of the most helpful interventions to treat these mental health concerns include grounding and relaxation techniques.

When focusing on grounding, counselors must engage the client’s physical world to assist the person in becoming present in the moment. For example, counselors may ask clients to locate an object in the room and provide an in-depth description. Relaxation techniques to practice include deep breathing and mindfulness meditation. Both types of techniques allow clients to practice coping skills during sessions that can translate to their everyday life experiences.

Stage 4: Selling victims. As retailers push survivors toward the consumers, the perpetrators continue to focus on marketing strategies and targeting potential consumers. Perpetrators often target large events (e.g., the Super Bowl, national political conventions) to take advantage of the crowds and high demand for paid sexual services. Those paying for the sex services, the consumers, exhibit low levels of depression and anxiety. These consumers often report avoiding relationship concerns or other mental health concerns, resulting in a desire to seek out sexual activity.

Because survivors have been a part of ongoing abuse and a cycle of victimization that they cannot break, counselors must use a systemic approach to providing services. For example, counselors need to provide information on shelters and building connections with family. Counselors may incorporate the use of technology and location services, safety words and discussing location with loved ones at all times.

 

Case example         

Toney, an 18-year-old multiracial, cisgender male, moved away from his caregivers’ home about one year ago and currently lives with a friend. He moved because of safety issues in his home and within the nearby neighborhood. When Toney was 16, his father died during a gang-related shootout at their home. Thus, Toney often felt afraid of engaging in a similar lifestyle and enduring similar consequences. Toney’s mother suffered from a severe substance use disorder that led to eviction from their rental home because she could not afford the rent. Toney and his mother became homeless.

While Toney was homeless, Kevin, a childhood friend, suggested that Toney come live with him temporarily as long as Toney obtained a job and contributed to the rent and utility bills. One day, Toney answered the front door, and a young adult male appearing to be about Toney’s age attempted to sell him a magazine subscription. Toney disclosed to the salesman that he was financially strapped. The young man told Toney about the large sums of money he made while selling magazine subscriptions and offered to put him in contact with the owner. Toney was intrigued by the idea of alleviating his financial troubles, and the young male immediately scheduled a meeting with the owner for later that night.

That evening, Toney met with the young salesman and the business owner in an abandoned parking lot, bought their sales pitch and decided to go to work. The business owner told Toney that he would need to move six hours away to another state because there was a high demand for work there and he would not have to pay any rent or utility bills. The business owner promised Toney the opportunity to travel and see many areas of the country while working in the job.

Thus, Toney left a day later to live in a weekly hotel in a new city with his new manager and several others. Upon arriving, the manager took them to a warehouse to pick up the product. They all began working the next day.

After a few weeks, Toney began grasping the reality of his situation. The job of trying to sell magazine subscriptions was strenuous and exhausting. He often worked 10- to 12-hour days while receiving limited rest and food. When Toney voiced concerns about the number of work hours he put in each day, his manager threatened him. The threats later escalated to physical assault when Toney again voiced his concern and when the manager perceived him to be underperforming at the job.

No matter how hard Toney tried, he could not meet the daily sales goal that the manager set for employees. When Toney failed to meet the daily sales quota, the manager either denied him his nightly meal or forced him to sleep outside of the hotel on the streets. As a result, Toney rarely ate and often did not receive the money he had earned while working. He was told that he would receive the money once the team had completed its sales goals for the area and had moved on to another city.

One day, while trying to sell magazines to a homeowner who declined to buy anything, Toney became agitated and started crying. He told the homeowner that he was in trouble and begged her to help him get home, across state lines. The homeowner had recently watched a documentary on human trafficking and invited Toney to use her phone to call the authorities.

The police arrived and took Toney’s statement about his work experiences. Fortunately, the responding officer had recently attended a departmental training on human trafficking, and she took Toney to the police station for further questioning and support. The officer connected Toney with a local nonprofit organization that provided multidisciplinary services, including professional counseling, to survivors of human trafficking. The organization offered shelter and provided Toney with career development services to help him obtain legitimate work. The shelter’s ultimate goal was to move Toney back to his hometown.

In counseling sessions with Toney, the counselor focused on direct questions to assess the nature of the human trafficking Toney had experienced. For example, “Did anyone threaten you or your loved ones?” and “Did you have difficulty leaving the work that you did selling door-to-door merchandise?” While initially reluctant, Toney eventually responded with answers that indicated his victimization. For example, he reported that his manager used threats and power and control tactics (such as denying Toney food, money and shelter) to force him to work.

Following assessment, Toney received counseling services focused on recovering from the abuse he had endured. Toney felt validated because he was not alone while accepting that he had fallen victim to human trafficking. The counselor and Toney focused on crisis intervention and stabilization in the beginning, which included discussions about adjunct services and basic needs assessments (e.g., food and clothing, job obtainment). Next, the counselor and Toney addressed the trauma, focusing on decreasing anxiety-provoking cues and scaffolding into addressing more severe cues and triggers. All the while, Toney and the counselor developed several grounding and relaxation techniques to use both in their sessions and in Toney’s real-world experiences.

One of the most valuable grounding techniques made use of a rock that Toney could hold whenever he felt distressed. The counselor taught Toney how to become present, while holding the rock, through discussions about the texture, shape and weight of the rock. Discussing these tactile experiences allowed Toney to focus on the here-and-now rather than attempting to escape feelings and thoughts.

Toney and the counselor also used a breathing method in which Toney would take a deep breath through his nostrils for at least three seconds and exhale through his mouth for three seconds. They determined that he needed to take at least three deep breaths during the exercise so that he could calm down.

In the final stages of counseling, Toney and the counselor developed an action plan to help him avoid falling victim to trafficking. That does not mean, however, that Toney took responsibility for the actions of others. Toney and the counselor reviewed the different needs he may have and how to meet those needs in a helpful manner.

While focusing on the trauma from human trafficking victimization, the counselor worked with Toney on obtaining a job at a local fast food restaurant. They chose this restaurant so that he could easily transfer to another store in his hometown once he felt comfortable with the transition. After three months, Toney finally returned home and moved back in with his friend, Kevin. He remained employed as a fast food line cook and began seeking education at a local culinary institute.

 

 

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Lamerial McRae is an assistant professor at Stetson University and a licensed mental health counselor in Florida. Her research and clinical interests include counselor identity development and gatekeeping; adult and child survivors of trauma, abuse and intimate partner violence; marriages, couples and families; LGBTQ issues in counseling and human trafficking. Contact her at ljacobso@stetson.edu.

Letitia Browne-James is a licensed mental health counselor, clinical supervisor and national certified counselor. She is a clinical manager at a large behavioral health agency in Central Florida and is in the final year of her doctoral program at Walden University, where she is pursuing a degree in counselor education and supervision with a specialization in counseling and social change. She has presented at professional counseling conferences nationally and internationally on various topics, including human trafficking.

 

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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.

 

Beyond words

By Nevine Sultan September 28, 2017

Attempting to work from a purely cognitive or emotional perspective with clients who have experienced sexual trauma is like trying to build a sturdy house without laying down a solid foundation. Facilitating recovery from sexual trauma demands the inclusion of the site of the original wounding — the body.

A clinical vignette

“Jerry” arrives seven minutes late for his intake appointment. He appears disoriented and confused.

“Please,” I say, inviting him to take a seat. When our eyes meet, he turns his gaze to the floor and explains, “I think I stopped at a gas station on my way here.”

Jerry’s face is flushed and his nostrils are fluttering. Although his head seems to be the most active part of him, I am drawn to Jerry’s feet, legs and hands. The rigidity in the lower half of his body is intense. Jerry’s left foot is twisted outward in a painfully supinated position. His hands are imprisoned beneath his thighs, and his shoulders are hunched forward. The word concave comes to mind. I feel a sense of hollowness in my core as I realize that Jerry is holding his breath like a dam straining to hold water that might cause irreversible damage if released all at once.

We talk briefly. Jerry tells me about his anxiety, the panic attacks that have besieged him up to twice daily over the past few months, his ceaseless hypervigilance, the memories that haunt him, the persistent need to wash his hands and the nights dotted with brief slumber from which he is jarred awake by horrific nightmares. “I’m also having problems with my girlfriend,” Jerry says. “I know I can trust her. It’s just … I can’t shake that feeling.”

As Jerry speaks, his voice is jittery and his lips tremble. His breathing shifts from closed to ragged. “I was out taking a walk in my neighborhood one night. A guy drove up to the sidewalk and asked for directions to the community pool.” Jerry’s pitch lowers, his articulation becomes less sharp, and he drifts inside himself. I shift in my chair to gently facilitate his return to the here and now. He looks up before continuing.

“As soon as I started talking, he got out of the car, opened the door to the backseat, and then … I don’t know. It happened quickly.” He pauses. “I woke up in a hospital. My wrists were really bruised.” Jerry scans the room with his eyes, which are filling with tears. “I couldn’t save myself.” He weeps, pulling his hands out from beneath him and rolling them up into fists.

My stomach clenches, and I feel a sting in my eyes. I am all too familiar with this narrative. Many of my clients who have suffered sexual trauma describe similar experiences of numbing and freezing and an overwhelming sense of self-betrayal. I take a deep breath and redirect my attention to Jerry, who is still sobbing. I give him a few minutes. As he recovers from his outburst, he returns to holding his breath.

“Jerry?” I say gently. He looks up. “Thank you for trusting me with that. See if it’s OK to exhale. Slowly.”

Understanding dysregulation

Every word that Jerry says matters. I note his narrative. It is significant. I also note the paranarrative — the cauldron of sensations, emotions and racing thoughts bubbling beneath the surface of his quivering demeanor. This agitated vessel is holding a fusion of fear, isolation, shame, avoidance, mistrust, physical and emotional numbing, negative beliefs, impulsivity, diminished agency and an outright inability to tolerate the present.

While Jerry’s thoughts and emotions are overly active, his body is entirely ignored. Consequently, he is caught in the unconscious frenzy of persistent fear and some terribly unforgiving stories: The world is dangerous. I will never be safe. I can’t protect myself.

The harm Jerry has endured did not compromise his thinking or his emotions alone, however. Jerry has suffered a severe wounding to his body; hence, his collapsed posture, his irregular breathing and his restricted movement, coupled with his overall sense of being overwhelmed and his inability to maintain a state of calm.

As French phenomenological philosopher Maurice Merleau-Ponty pointed out in his seminal text, Phenomenology of Perception, our bodies are the agents by which we exist in the world. They are also the receptacles of memories that, often vanished from our conscious awareness, are still deeply etched within our being. When those memories are triggered, we experience suffering at a highly existential level that transcends consciousness. Facilitating the recovery of clients who have experienced sexual trauma must include opportunities for repairing connections with all dimensions of their being.

John Hughlings Jackson, known as the “father of English neurology,” outlined a human nervous system composed of three parts: social, sympathetic and parasympathetic, which has since inspired Stephen Porges’ polyvagal theory. Jackson’s model is hierarchical: The higher elements inhibit the lower elements. When a higher element on the hierarchy fails, a lower component takes over.

The highest element of the nervous system is the social one, responsible for relational contact and communication. Lower on the hierarchy is the sympathetic nervous system, which kicks in when we experience a disturbance in our inner or outer environment, thus activating our fight/flight/freeze/dissociate response. Should we not fight or flee, we plunge into freezing, immobility and dissociation. Unless the parasympathetic nervous system is reactivated, we remain frozen, incapable of responding to our environment.

Paradoxically, nonthreatening surprise situations are likely to elicit a sympathetic nervous system response, whereas threatening situations are likely to elicit a parasympathetic response, which is why many of us freeze or dissociate when confronted with a seemingly hostile situation. A healthy nervous system is one that self-regulates through a balance of sympathetic and parasympathetic functioning — that is, an arousal-activation event is followed by a period of rest and digest. An unhealthy nervous system, on the other hand, remains in either hyper- or hypoarousal, giving rise to startle, panic, hypervigilance, restlessness and emotional flooding, or to emptiness, exhaustion, disorientation, dissociation and emotional numbing, respectively. Clients who have not resolved traumatic events are often stuck in hyper- or hypoarousal.

In the aftermath of a traumatic event, survivors are likely to develop generally maladaptive coping symptoms that offer temporary relief from dysregulation. These coping symptoms include various process and substance addictions, obsessions and compulsions, and self-harm. Regardless, clients suffer the following interruptions:

  • Physical/perceptual (inaccurate kinesthetic reactions to perceived threat, anxiety, dissociation, collapse)
  • Contextual (difficulty perceiving and making sense of surroundings)
  • Emotional (fixation on fear, rage or sadness)
  • Cognitive-behavioral (intrusive, racing thoughts; memory loss; self-destructive patterned behavior)
  • Spiritual/existential (loss of sense of self)

Jerry tends to cycle between hyper- and hypoarousal, as evidenced by his frequent experiences of hypervigilance and panic attacks, and his often collapsed and frozen posture. When agitated, he attempts to manage his dysregulation in a number of maladaptive ways, including engaging in impulsive (e.g., breaking up and making up with his girlfriend repeatedly) and compulsive behaviors (e.g., continually washing his hands).

Although traditional cognitively and emotionally oriented psychotherapy approaches may help Jerry ease some of these coping behaviors, they do not include methods for addressing his dysregulation. Working with Jerry’s physical process allows me to help him identify when he is in hyper- or hypoarousal and bring himself back to what leading neuropsychiatrist and interpersonal neurobiologist Daniel Siegel refers to as one’s “window of tolerance,” or the zone in which our arousal state is balanced.

Honoring the somatic narrative

The somatic approach to healing trauma was inspired by a phase-oriented model for treating trauma and dissociation that was established in the early 20th century by French psychotherapist Pierre Janet. The somatic approach requires an understanding of how nervous system dysregulation is activated as a consequence of trauma and which parts of the body and brain are involved. The counselor uses this information to help clients create a sense of safety, to facilitate clients’ use of internal resources to regulate arousal and enhance self-efficacy, and to help clients address traumatic memories and explore novel ways of being in the world. Interventions include focus on nonverbal experience, kinesthetic awareness and reshaping body movement.

In the aftermath of his traumatic assault, Jerry’s ability to organize his experience was compromised, resulting in dysregulation of arousal, challenges tracking his surroundings and increased cognitive and emotional processing. This sent his thoughts and feelings into overdrive, making it difficult to control his impulsivity. With his inability to self-regulate, Jerry is virtually incapable of remaining connected with his present moment, and specific trauma-related (and sometimes neutral) stimuli can trigger an immediate impulsive response.

According to Pat Ogden, the pioneer behind the popular attachment-based somatic approach to healing trauma known as sensorimotor psychotherapy, a primary task faced by counselors working from a somatic approach is to help clients create a balance among the various processes used to organize experience. This is done using a bottom-up model that views human experience as an initially sensory process that informs emotion, which then informs thought and behavior. Focusing on the here and now is especially important when using a body-centered approach because it allows the counselor to address how a past event is manifesting in the present.

Finally (or perhaps first and foremost), when working with the somatic dimension, high levels of therapist presence and attunement are needed to support a therapeutic alliance with appropriate boundaries that is built on safety and trust.

Creating shared space

Essential to facilitating Jerry’s connection with his physical process is my personal embodiment — that is, my ability to be in contact with and present in my own body. By anchoring myself in my body and my present-moment experience, I am better able to create an empathic space for our encounter.

I use my sensory experiences to inform the therapeutic process and guide me toward a well-rounded understanding of how Jerry exists in the world based on how he exists in the therapy room. Understanding the experience of my body when I am in contact with Jerry helps me reach out within our intersubjective space with the deepest respect for his pace while acknowledging that I am affected by his experience. From this place of compassion and empathy, sharing and being, and phenomenological engagement, an integrative somatic process begins in which I serve as a bridge between Jerry and the rest of the world.

“When you are ready,” I say to him in gentle invitation.

Organizing the client’s experience in the here and now

I listen to Jerry’s verbal narrative. I also attune to the story his body is telling and how my own body is receiving that. What body postures does Jerry fall into as he recounts specific parts of his story? What gestures accompany certain words, phrases or recollections in the here and now?

Such physical manifestations are indicative of how Jerry’s body has encoded certain events implicitly. Jerry is physically manifesting content from his implicit (unconscious), somatic memory of the traumatic event that may or may not be congruent with his declarative (conscious) memory. Keeping in mind the fallibility of declarative memory, working from a somatic approach supports access to Jerry’s implicit memory, which offers us additional insight into his experience.

Attending to Jerry’s somatic narrative, I notice that his fists hold the highest energy. My own fists are wound so tightly that I can feel my nails digging into my palms. I also notice that I am holding my breath in anticipation. I release my breath, unfold my fingers and share some observations with Jerry in the form of brief contact statements designed to enhance his awareness.

I also pose exploratory questions. “I’m noticing that as you talk about feeling incapacitated in the moment you were grabbed, your hands are balled into fists. Would it be all right to bring your attention to your hands for a moment?” Helping Jerry consciously connect with the most reactive part of his body invites his capacity to self-witness and be self-aware. This activates the prefrontal cortex that, according to body-centered trauma expert Bessel van der Kolk, is responsible for emotion regulation, cognitive and social behavior, and decision-making.

As Jerry accesses his past experience in the here and now from a nonreactive place, he is better able to observe it, recognize that it happened in the past, notice how it is manifesting in the present and identify new ways of understanding it. Next, we work to identify the emotions that arise with the declarative and implicit memories of the experience and any thoughts that accompany the physical and emotional manifestations.

“What are you sensing in your fists right now?” I ask. “Examples of sensation are tingling, tightness, cold, heat.”

“They’re stuck,” Jerry says. “I can’t do anything with them.”

I ask Jerry to name the feelings that accompany that sense of stuckness. “Examples of feelings are anger, sadness, guilt, fear. ‘I feel …’ Can you fill in the blank?”

Jerry stares at the ground. “I feel … angry.” He begins to weep inconsolably. “I’m so, so angry.” He drops to the floor and curls into a fetal position. I give him a few minutes to be where he needs to be, to experience being balled up and angry.

“I’m so mad at myself. I didn’t save myself. Who does that?” I recognize that I didn’t have to invite Jerry to reflect on any thoughts accompanying the emotion and the sensation; the thoughts are emerging on their own.

Minutes later, Jerry is still holding his fists, but his tears are subsiding. I grab a box of tissues and sit on the ground near him, close enough to offer the nonphysical support he may need. I pull out a tissue and drape it gently over his left fist. He flinches and opens his eyes, looking straight ahead.

I wonder if it might be helpful to invite some awareness around how he is organizing this experience. “What are you holding inside your fists, Jerry? And what is that doing for you?” Jerry continues to look out into the ether. “Your fists,” I prod gently. “If your fists had a voice and could speak, what would they say? ‘I …’ Can you fill in the blank?”

Jerry is silent for a few seconds. “I … I am …”

“Yes, Jerry. Keep going,” I encourage him.

“I am … very angry,” he offers meekly.

“Is that what the anger inside of your fists sounds like?” I nudge gently. Jerry shifts slightly in his fetal position and then stops. “What does your body need to do right now?” I ask. “Expand? Contract? Walk away? Move closer? Is it OK to explore that need?”

“I think I need to move,” Jerry says. Without further invitation, he sits up. His upper body is still collapsed, and he seems undecided. I invite him to attend, once again, to what his body needs. Jerry inhales a little more deeply, expands moderately with his intake of breath, tightens his fists further and bellows, “I AM SO ANGRY!”

“Say that again,” I urge. “Give your fists the voice they need.”

“I AM SO ANGRY!” he screams, over and over. Twenty times. Thirty times. “I WILL NEVER LET ANYONE DO THIS TO ME AGAIN!” Jerry says even louder, holding his fists chest high and shaking them like he has someone by the collar.

Once Jerry has experienced a full release of energy, his tight fists unfold, although with some reservation. “Would it be OK to let go of the rest of that?” I invite.

Jerry’s eyes close, and I realize he may be unwilling to let go. I offer a compromise. “You don’t have to let go of your anger forever,” I say. “Maybe you can leave it in a safe place so that you can have it back whenever you want it.”

Jerry seems open to this idea. After some deliberation, he looks at a print hanging on the wall behind me and says, “I think I’ll leave it behind that picture.”

Jerry and I have just worked through a process of using an implicit memory (balled-up fists) connected with his traumatic incident to initiate a recalibration of his nervous system. This process involved:

a) Creating a shared space facilitated by my presence

b) Helping Jerry identify different facets of memory (implicit and declarative)

c) Using contact statements to help Jerry recognize the orienting patterns he is using to organize his experience (“I’m noticing …”)

d) Inviting Jerry to name his sensory, emotional and cognitive experience (“What are you experiencing …?”)

e) Allowing Jerry’s body to tell its narrative (“If your fists had a voice and could speak …”)

f) Exploring modification of Jerry’s orienting patterns (“What does your body need right now?”) and experimenting with new ways of being

g) Restoring empowering actions (“Give your fists the voice they need.”)

The next step involves making sense of our process. The hope is that Jerry will use his new understanding of his experience to make new choices informed by the here and now.

Creating meaning and energizing change

“What was that like for you?” I ask.

“I don’t know,” Jerry says. “I feel like a heavy load has been lifted.” I nod. “From these,” he continues, raising his hands.

I acknowledge and affirm Jerry’s reflection. “Those fists were holding on pretty tight. What did it mean to hold tight?”

“I think … I felt in control.”

“Can you say more about that?”

“Yeah. Like I wasn’t going to lose it, I guess.”

I feel that Jerry and I are in a safe enough place for my next question. “What would happen if you allowed yourself to completely lose it?” Jerry clenches. “OK to exhale?” I invite.

Jerry releases his breath slowly. “I don’t know.”

“Jerry?” I invite him to make brief eye contact with me. “I’m not sure I buy that.” I smile gently. “What would happen?”

Jerry thinks but maintains eye contact. “I mean, I just lost it, right?”

I offer a perspective: “Seems like you trusted yourself with that too.”

“I did,” he says solemnly.

“What is it like for you to trust yourself?” I ask. “‘I …’ Can you fill in the blank?”

“I feel pretty big right now.”

“Hmm. What does big look like?” I invite. “Can you show me?” Jerry lifts his body and expands his chest. Although he does this slowly and with seeming caution, I am aware that he has given himself permission to explore a place beyond his wound. I open the door for a final inquiry that will help Jerry take what he has learned about resourcing himself outside of the therapy room: “What might you do with that bigness, Jerry?”

Working through roadblocks

Accessing and working with certain memories in the here and now is not always a straightforward process. In Jerry’s case, he sometimes exhibits an aversion to being in the present. For example, although Jerry shows relative ease connecting with his anger, in a later session he experiences great difficulty accepting his shame.

Jerry’s resistance manifests, initially, as indirect eye contact and fixation on the ground. Once we begin exploring this and Jerry identifies the emotions and thoughts connected with it, he manifests an outburst of physical agitation that is marked by twitching in his chair until he falls to the ground.

I invite Jerry to remain seated on the floor and connect with the ground (using a process we call grounding), which helps him feel connected to and supported by something outside of himself. Next I ask him to explore his center of gravity by way of a process called centering, which brings his attention back to his physical experience. Finally, I suggest containment, a self-holding exercise designed to facilitate self-regulation and awareness of one’s boundaries and overall physical presence.

Because of their focus on the physical, these exercises shift clients’ attention from the self-destructive emotional and cognitive narrative to their internal resources. With this, the counselor is tasked with pacing the session so that the client is not overwhelmed. Introducing these safety-enhancing exercises is often helpful as sexual trauma clients experience the need to recalibrate from the potentially overpowering experience of confronting their trauma.

Establishing a time frame for the therapeutic process

Clinicians working from a somatic approach are highly aware of the challenges of creating time parameters for their therapeutic work. On the other hand, it is not uncommon for clients to ask, “How long will I be in therapy?” My response is that it depends on a number of factors, including:

1) Whether the traumatic event was a single, first-time incident or is recurring

2) The client’s developmental history (i.e., milestones, attachment patterns)

3) The client’s current coping strategies

4) Systemic factors (i.e., family, community and broader social support)

5) Client openness to working with the body

6) Therapist consistency and the quality of the therapeutic alliance

That said, somatic therapy tends to be time intensive, unlike, say, brief solution-focused or cognitive-behavioral work. Jerry attended weekly 80-minute therapy sessions for approximately 10 months, followed by biweekly 50-minute sessions for three months. He is currently coming in for monthly 50-minute check-ins.

Although Jerry has not forgotten his traumatic incident, he has learned how not to be hijacked by memories, how to self-regulate when confronted with somatic, emotional or cognitive triggers and how to tap into internal resources (including his body) to address present-moment needs.

Closing reflections

Embracing a somatic approach in working with Jerry’s sexual trauma engages his verbal and nonverbal narratives, opening a door to reshaping his way of being in the world and catalyzing new intentions and experiences. It also helps us focus on what is versus what was or what might be.

Working in the present enhances Jerry’s awareness of who and how he is in the world, what he does and how he does it, and how remaining stuck in the past or allowing himself to be hijacked by the future are choices he can modify as he works to reconnect with his window of tolerance. Being aware brings present-moment possibilities and options center stage. The emphasis is no longer on irreversible past or anticipated future experiences but on what is happening in the here and now.

Thus, clients take responsibility for their needs, feelings, thoughts and actions. Taking responsibility and ownership of situations and experiences is, in itself, a holistic, anchoring and awareness-enhancing behavior. With it comes an increased ability for clients to push the boundaries that are stifling their self-expression, identify immediate needs and engage in self-mobilization, creative experimentation, somatic expression and self-regulation, all of which are at the heart of an existence that has made peace with its past and is grounded in the present. As clients’ awareness is ignited on a holistic level, they are empowered to decide whether their patterned behaviors still serve a purpose and how those behaviors can be modified to meet present needs.

How we inhabit our bodies reflects our way of being in the world. Through our bodies, we sense and experience, receive and perceive. Exploring the physical body and its manifestations of past sexual trauma helps clients integrate the physical, emotional and cognitive dimensions of their experience. Sensory-kinesthetic exploration brings history to life in the present and anchors it here, where it is more accessible.

Conscious engagement with the body’s innate knowledge permits clients to access their own strengths in the process of healing. How empowering and transforming for our clients who have suffered from sexual trauma to recognize that their well-being exists within their own bodies — the very site of their original wounding.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Nevine Sultan is an assistant professor of clinical mental health counseling at the University of St. Thomas in Houston and a licensed private practitioner specializing in trauma, dissociative disorders and grief. She embraces an embodied phenomenological approach to counseling and psychotherapy, research and teaching. Contact her at nevine.sultan@gmail.com.

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.