Tag Archives: sexual abuse

Addressing intimate partner violence with clients

By Bethany Bray June 24, 2019

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

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

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

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

Handle with care

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

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

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

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

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

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

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

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

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

Power and control

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hard questions, empathetic listening

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Planting seeds

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

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

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

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

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

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

Couples counseling and safety

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Relationships post-IPV

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

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

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

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

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

 

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IPV: Need-to-know points for counselors

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

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

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

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

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

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

 

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Important resources

 

Margaret Bassett recommends the following books for practitioners:

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

 

Related reading, from Counseling Today:

 

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

Letters to the editor: ct@counseling.org

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

What’s left unsaid

By Lindsey Phillips January 3, 2019

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

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

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

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

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

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

Putting on a detective hat

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

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

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

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

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

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

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

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

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

Speaking a child’s language

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

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

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

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

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

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

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

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

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

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

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

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

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

Long-lasting effects

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

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

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

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

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

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

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

Finding self-compassion

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

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

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

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

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

Regaining a sense of safety

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

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

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

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

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

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

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

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

Taking back control

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

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

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

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

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

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

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

The hero who told

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

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

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

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

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

 

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

Letters to the editorct@counseling.org

 

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

Talking about #MeToo

By Laurie Meyers August 31, 2018

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

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

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

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

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

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

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

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

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

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

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

Moving on from #MeToo

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

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

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

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

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

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

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

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

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

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

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

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

It takes a village

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

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

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

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

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

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

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

When #MeToo is painful

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

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

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

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

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

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

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

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

What are men learning?

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

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

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

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

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

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

 

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Additional resources

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

Counseling Today (ct.counseling.org)

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

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

 

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

Letters to the editor: ct@counseling.org

 

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

Effective ways to approach sexual assault response

By Hasmik Chakaryan July 10, 2018

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

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

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

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

Crisis intervention

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

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

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

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

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

 

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

 

Response to assault based on immediacy

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

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

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

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

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

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

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

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

Forensic exams

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

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

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

Immediate vs. delayed reporting

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

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

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

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

No report to law enforcement

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

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

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

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

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

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

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

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

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

Student/supervisee disclosure

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

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

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

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

Other considerations

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

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

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

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

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

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

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

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

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

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

 

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

Letters to the editor: ct@counseling.org

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

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.

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