Tag Archives: sexual abuse

Becoming shameless

By Laurie Meyers April 25, 2017

You should be ashamed of yourself.” How many of us have heard — or perhaps even used — that phrase? Being on the receiving end of such a pronouncement is never pleasant. More important, experts firmly believe that attempting to wield shame as an instrument of change is both ineffective and harmful. In fact, many clinicians say that shame is intertwined with an abundance of issues that typically bring clients to counseling. Furthermore, it often stands as a significant barrier to healing.

In her book I Thought It Was Just Me (But It Isn’t), Brené Brown defines shame as “the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging.” The research professor at the University of Houston’s Graduate College of Social Work believes that shame has become a kind of silent epidemic in society that serves to isolate us and thus damages our sense of connection to others.

Thelma Duffey, the immediate past president of the American Counseling Association, agrees. One of her main initiatives as president focused on issues surrounding bullying and interpersonal violence, both of which can leave people struggling with a deep-seated sense of shame. “I see shame as a deeply painful feeling that people experience when they feel exposed, inadequate or especially vulnerable,” she says. “Unforgiving and powerful, shame can leave many people feeling unworthy and incapable.”

Bullied into shame

The practice of actively shaming others, particularly through bullying behaviors, is all too common in our culture, says Duffey, a practicing licensed professional counselor and licensed marriage and family therapist for more than 25 years.

“Bullying can trigger feelings of shame, leaving people feeling defenseless, embarrassed and confused,” she says. “Some feel such a strong sense of self-consciousness and become so preoccupied with avoiding shame-inducing situations that they withdraw from others, which can lead to an excruciating form of isolation.”

Without the consistent presence of love and support in a person’s life and the provision of a realistic viewpoint from others, there is no counterbalance to shame’s narrative.

“Imagine holding a broken mirror of yourself and believing that the distorted image is what you truly look like,” Duffey says. “Your perception would be off, wouldn’t it? Now imagine you are holding a broken mirror that reflects a distorted image of who you are as a person. If you believe this distortion, it won’t be easy to feel good about yourself or to connect with other people who love you. It will probably lead you to see the world as an unsafe place. In all likelihood, you’ll have to create ways of coping with these images just to survive. Too many times, these coping strategies ultimately keep us from the very connections we desire.”

Duffey says there is an antidote. “I believe that developing a sense of self-compassion is at the core of conquering shame,” she says. “Unfortunately, self-compassion is not always easy to come by, particularly when a person has been mistreated, publicly mocked or hurt, as is generally the case with any bullying situation. In fact, introducing the idea of self-compassion can actually make people wince when they live with feelings of shame, because it sheds light on their self-loathing perceptions.”

Counselors can use a variety of methods to help clients develop self-compassion, but a strong therapeutic bond is the most essential ingredient in that process, says Duffey, who is also a professor and chair of the counseling department at the University of Texas at San Antonio. One of the interventions she uses is Emotional Freedom Techniques (EFT).

“EFT has been described as a type of psychological acupressure that can help unblock distressing situations,” Duffey says. “The idea is to restore balance to the body’s energy field to move negative emotions that can keep us stuck. I also see it as a way for people to center themselves when they are in their uncomfortable emotions and to connect with themselves in a more soothing way.”

Duffey says that EFT in its traditional form has a sequence that involves identifying the problem — for example, shame — and then having clients ask themselves how they feel about the problem right now. Clients then rate the level of intensity of the problem, with 10 being most intense and zero being least intense. Next, the counselor and client come up with a “setup” statement that acknowledges the problem and follow that with an affirmation. Clients then repeat the statement and affirmation while performing a kind of “psychological acupuncture” that involves taking their hands and tapping five to seven times on the body’s “meridian” or energy points.

“A person experiencing shame and with memories of bullying might say something like, ‘Even though it is not always easy for me to see my own value, I deeply and completely love and accept myself,’” she says. “Or, ‘Even though I can still remember the horror of being made fun of, excluded and shunned, I can be on my own side now. And I am not alone. In fact, I am working on loving and accepting myself.’”

Once a person connects with the problem and the idea of loving, self-compassionate affirmations, he or she can use those affirmations to process all sorts of experiences, Duffey says. “The idea, of course, is not about thinking positively or practicing self-delusion,” she notes. “Rather, it is about really being honest about what hurts and confronting these feelings, [and then] offering affirmative statements of hope and compassion while tapping into the body’s energy using acupressure points.”

Duffey recommends the website thetappingsolution.com for those who would like to learn more about EFT.

The trauma-shame connection

At the ACA 2017 Conference & Expo in San Francisco this past March, licensed mental health counselor Thom Field presented “For Shame! The Neglected Emotion in PTSD.” In the session, he explained that shame is a significant component of posttraumatic stress disorder (PTSD), particularly in cases of interpersonal trauma, such as child abuse and intimate partner violence.

Because PTSD’s most common symptoms — hypervigilance, nightmares, flashbacks, intrusive memories and physiological hyperarousal — are all related to fear of external danger, experts in the trauma field have traditionally focused on fear as the primary emotion in PTSD, noted Field, a member of ACA. Using this assumption, therapy techniques for PTSD have focused on methods such as exposure therapy, he said. In exposure therapy, clients are asked to revisit the trauma multiple times because repetition has been shown to help lessen the physical and emotional effect of these memories.

However, new research suggests that trauma survivors often also fear being rejected and exposed as weak. This fear engenders a sense of shame, said Field, an associate professor and associate program director of the counseling master’s program at the City University of Seattle. He explained that the shame is fueled by a persistent negative self-appraisal in which clients who have experienced interpersonal trauma often berate themselves with statements such as “I am weak — an easy target”; “Something is wrong with me if I can’t prevent these things from happening”; or “Why didn’t I do something?” Trauma survivors often feel inadequate, inferior or powerless to affect their own environments, he added.

Field believes that counselors must understand the role of shame to help many of these individuals who are living with PTSD. “Shame is an emotion that arises when a person feels inadequate or corrupted by an irredeemable act or a contaminating event,” Field explained. “The person feels undesirable and unattractive and fears the perceived judgment of others.”

It is also important for counselors to differentiate shame from guilt, Field noted. He defined guilt as regret for a specific action that is bound to external circumstances. It is a feeling connected to what one has done rather than — in the case of shame — what one is, Field emphasized. Whereas guilt can motivate prosocial actions such as reparation, shame usually motivates self-protective actions such as withdrawal or lying to protect secrets, he pointed out.

Among the factors that increase feelings of shame in those who are experiencing PTSD or interpersonal trauma are the attribution of responsibility (such as the perception that having HIV or AIDS is that person’s “fault”); the level of visibility and an inability to “hide” (because of circumstances such as physical disability or disfigurement); and being marginalized, Field said.

Feelings of shame may prevent some people with PTSD from seeking counseling, and even those who do seek counseling may deny the presence or impact of trauma if a counselor asks them about it directly, Field said. Harboring a sense of shame may also make it difficult for clients to trust others, he added, so counselors must take care to proceed slowly and focus on developing the therapeutic alliance. These clients need to be made to feel safe enough to reveal their secrets and process their fear of rejection, humiliation and judgment by others, he emphasized.

An important step in the process is for counselors to facilitate client autonomy with what Field termed “pre-questions.” For instance, a counselor might say, “It seems like it might be helpful to revisit this event. How ready are you to face that?”

“If you dive in [yourself as the counselor], it feels [to the client] like it’s not voluntary,” Field explained. When counselors press the processing of shame before clients are ready, it can cause clients to, in essence, feel shame about their shame.

Counselors should also let clients know what to expect when they decide to share their trauma. For instance, Field said, “The client is going to feel physiological symptoms.”

Through client mirroring and active listening, counselors can help establish a sort of holding container for these clients’ emotions. This takes away the pressure of having to “do” anything with those emotions, allowing clients to feel safe simply “sitting” with their feelings until they are completely ready to process them, Field explained.

Like Duffey, Field thinks that self-compassion is essential to overcoming shame. The ultimate goal is to teach clients to accept their current and past experiences without self-judgment, he said. Field recommended that counselors use some of the exercises developed by psychologist and self-compassion researcher Kristin Neff. These include having clients imagine how they would treat a friend who was in the same circumstance, writing letters to themselves from a place of compassion, changing critical self-talk through reframing, keeping a self-compassion journal and practicing loving-kindness meditation.

The lasting shame of abuse

For clients who were sexually abused as children, the sense of shame is almost primal, says ACA member David Lawson, who has worked with trauma victims for more than 25 years. Time after time, women in their 30s and 40s have sat in Lawson’s office and insisted that it was somehow their fault that they were sexually abused as children.

“They say, ‘There must be something wrong with me.’ ‘I’m bad.’ ‘I’m contaminated,’” says Lawson, a counseling professor at Sam Houston State University in Texas who has conducted extensive research on trauma. “I’ve even had several people say, ‘I must be evil in some way for this to happen to me.’”

When parents are the perpetrators of sexual abuse, the abuse survivors’ sense of shame is particularly strong, Lawson says, because humans are wired to seek attachment with parental and other caregiving figures. To maintain this attachment, child victims must rationalize the abuse. As a result, these children often tell themselves that they are bad rather than accepting that the parent is not good, Lawson explains.

Another factor that contributes to these children’s feelings of shame is the perceived “benefits” they received from their abusers, Lawson says. He recounts the story of a female client in her 20s.

“She was abused from the ages of 5 to 16 by her father [until] her mother finally left the father. Years later she came into therapy, and I said, ‘Tell me about some of the best times in your life.’ She said that they were with her father: ‘At times I felt like I was my father’s girlfriend.’ There were benefits for her. He would buy her things and take her places, which he did not do with her siblings. Then, at night, the abuse would happen.”

The woman went on to confide to Lawson that the worst times in her life were also with her father. “He would tell her, ‘No one else will love you. You are worthless. No one will have you but me,’” Lawson says.

Abusers often use this technique, aware that if their victims feel there is nowhere else they can go and be accepted, there is a greater chance they will stay in the only place they seem welcome. This “acceptance” increases victims’ sense of connection to their abusers, Lawson says.

These patterns are distinct and specific to what Lawson calls the “trauma subculture.” The behaviors and beliefs of survivors of sexual trauma are so antithetical to most people’s expectations that outsiders — including many counselors — often find their reactions difficult to understand, he says.

“One of the hardest things for my students to get over is the way that [sexual trauma survivors] look at the world and the way they think about themselves,” Lawson says. “We just want to run over and hug them, but that just ramps up their shame because they don’t believe that they’re worthy.”

Early in his career, Lawson learned how premature sympathy and acceptance could backfire. He told a client that the abuse the client had suffered was not his fault, and the client got quite angry with Lawson, rejecting his help because he genuinely thought that Lawson didn’t know what he was doing.

What Lawson learned with that experience is that in immediately trying to correct clients’ beliefs about their abuse, counselors threaten to take away a major part of the identities that clients constructed as a way to survive. Today, Lawson urges counselors to move slowly with these clients and first work toward establishing a strong therapeutic bond.

“It may take many sessions just for them to feel comfortable,” he says. “These people don’t trust anyone, so to think that they’re going to trust in a few sessions is naïve and counterproductive.”

Start by accepting these clients where they are and reflecting on the dilemma they are facing, Lawson advises. “On the one hand, they feel an enormous amount of allegiance. On the other hand, they have strong feelings of hate,” he explains.

After counselors have established a relationship, they can introduce the idea of talking about the client’s experience. A counselor could say, “Talk to me about your relationship with your father and how you came to the conclusion that you’re not worthy of anyone else’s love,” Lawson suggests. He adds that counselors must give clients time to reflect and reconstruct how they came to their conclusions about self-worth.

Lawson says that once he asks those kinds of questions and lets clients unpack and narrate their experiences at their own pace, they are usually able to begin seeing how their erroneous, negative self-beliefs were shaped by what happened to them. He cautions, however, that intellectual understanding is not the same as emotional acceptance, which can take additional time. Lawson notes that some experts view this kind of shame as an annihilation of self. Survivors may feel that there is no part of themselves that is worth forgiving, he explains.

In the process of helping clients see themselves as redeemable, fully acknowledge the abuse that happened to them and grieve what was lost, counselors should be supportive, but they must also modulate their affirmation to a level that the client can handle, Lawson cautions. “If we’re too warm and nurturing, the client takes that and rejects it and sees us as incompetent because we don’t understand,” he says.

For that matter, trauma (and shame) may not be the stated concern that brings survivors of sexual abuse into counseling in the first place. Instead, the presenting issue may be depression, anxiety, relationship difficulties or something else, Lawson says. “I deal with whatever they present with and try to help them get some relief from those things,” he says.

But along the way, Lawson introduces the idea of addressing and processing the trauma with clients. He may approach it in a very general way at first, perhaps by asking clients to talk about the trauma as if it happened to someone else.

Lawson may also use a “lifetime line.” He starts by asking clients to pick a year of their lives and talk about everything they can remember about it — good and bad. By doing this, clients are not only processing trauma, but also remembering that there were positive events in their lives too, he says. Lawson also has clients write down all the positive memories to help remind them, as they construct their life narrative, that the abuse does not encompass their entire life.

Lawson says he finds narratives, either written or spoken, vital in treating clients’ shame. By showing compassion for their narratives, counselors can help clients start to feel compassion for themselves, he says.

Shame beliefs

Gray Otis, a licensed clinical mental health counselor in Cedar Hills, Utah, believes that shame is typically a component in traditional mental health disorders such as depression and anxiety. In fact, he says, shame likely underlies most issues for which clients come to counseling.

“Typically, the individuals who come for treatment have strongly held negative core beliefs about themselves,” says Otis, who has extensive postgraduate training in trauma treatment. These negative core beliefs are not just about behavior, he adds, but actually inform people’s sense of who they are.

Otis, whose counseling approach is centered on positive behavioral health, thinks that these beliefs stem from incidents that evoke a sense of shame in the person. Such events typically take place in childhood or adolescence, but adults can experience them too. These incidents may or may not be described as “traumatic.” Negative core beliefs can be caused by an accumulation of painful events, such as consistently being criticized as a child or going through a divorce. The resulting beliefs can take many forms, Otis says, but they generally revolve around reinforced themes — for instance, a person growing to believe that he or she is stupid, unworthy, undeserving and unlovable.

Otis believes the key to addressing clients’ mental health issues is uncovering and dispelling their shame-based negative core beliefs. The difficulty counselors may face in unraveling a client’s core beliefs will vary depending on the person and the complexity of his or her presenting issues. However, Otis says he finds it relatively straightforward to uncover many of these beliefs. When he asks clients to identify some of the things they believe about themselves that are not positive — Otis directs them to use “I am” statements — they can usually identify five or more negative beliefs, he says.

What is particularly potent about the beliefs underlying these “I am” statements is that people tend to perceive them as being inherent, unchangeable personal traits, Otis says. Many of these core beliefs are subconscious, he adds. By helping clients bring them to the surface and recognize that they are beliefs, not traits, counselors can assist clients in replacing negative beliefs with positive core beliefs.

Otis does this by having clients explore the origins of one of their negative beliefs, asking them when they started believing this internalized truth about themselves and what happened that contributed to that belief. Otis then asks clients to focus on one of their most distressful experiences and “freeze” it, as if it were a photograph. He then urges them to describe the emotional sense of the experience, identify their degree of distress and state the shame-based negative core belief (such as “I am never good enough”).

The next step is for clients to specify the positive core belief they desire. Otis then helps them identify life events that reinforce the new, positive core belief. He asks clients to remind themselves of these reinforcing events daily as a way to continue strengthening their positive belief. Next, Otis has clients revisit the experience that engendered the negative belief, and he talks with them about how the event was misinterpreted.

Otis says he also uses methods such as sand tray therapy, eye movement desensitization and reprocessing, and cognitive behavior therapy not only to help clients develop more positive beliefs but also to become more resilient. He emphasizes, however, that the most important factor when working with shame-based negative core beliefs is a strong therapeutic alliance.

Ultimately, he says, helping clients rid themselves of persistent shame is what opens the door to healing.

 

****

 

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

Letters to the editor: ct@counseling.org

 

****

 

 

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

Counseling survivors of sexual assault

By Brooke Bagley and Joel Diambra August 26, 2016

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

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

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

 

Phase 1: Assessment and education 

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

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

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

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

Phase 2: Rapport and strengths

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

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

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

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

Phase 3: Cognitive intervention

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

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

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

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

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

Phase 4: Emotion focused

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

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

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

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

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

Phase 5: Trauma narrative

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

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

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

Implications and model tenets 

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

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

 

****

 

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

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

Letters to the editor: ct@counseling.org

 

****

 

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.

Going beyond ‘no means no’

By Laurie Meyers August 25, 2015

Survivors and activists have sought for decades to shine a light on the issue of sexual assault on college campuses with everything from Take Back the Night events to No Means No education campaigns. A Columbia University student who graduated in May made national headlines when she spent her senior year carrying a mattress with her everywhere she went on campus to represent the dorm room bed where she alleges she was raped as a sophomore. The alleged perpetrator was NOallowed to remain on campus.

And yet the debate about how best to address sexual violence on campus rages on. For that matter, researchers can’t even seem to agree on how often sexual assault occurs on campus. On the one hand, the 2006 federally funded Campus Sexual Assault Study of more than 5,000 women and 1,000 men at two large (unnamed) universities found that 1 in 5 female college students had been sexually assaulted. However, a 2014 Department of Justice report based on the answers of 160,000 respondents in the National Crime Victimization Survey found that an estimated 0.6 percent of female college students had been sexually assaulted.

Experts have pointed out significant shortcomings in both surveys, but some recent data, gathered in the first quarter of the year and released in June, aligns with the 2006 study. These findings come from a joint Washington Post-Kaiser Family Foundation poll of more than 1,000 randomly selected recent college graduates. The poll defined sexual assault as five types of unwanted contact: forced touching of a sexual nature, oral sex, vaginal sexual intercourse, anal sex and sexual penetration with a finger or object. One in 5 of the female respondents reported having been sexually assaulted in college. Five percent of the poll’s male respondents also reported being sexually assaulted while in college.

Regardless of the numbers, few would argue that any sexual assault is one too many. Counselors who are on the front lines of prevention efforts on college campuses say that decreasing the number of sexual assaults can’t be accomplished simply by raising awareness but must also be accompanied by widespread behavioral and cultural change. That is a complex and daunting task, but the counselors we spoke to — who are engaged in research or are working with campus programs — believe that current campaigns to reduce sexual violence through education sessions, campuswide activities and, in some cases, even the theater, can bring about lasting change.

A holistic approach to prevention

For decades, prevention efforts failed to address all of the factors that contribute to sexual assault, instead placing the onus on individual women and what they should do to prevent being assaulted, says Laura Hensley Choate, an American Counseling Association member who researches and writes about women’s and girls’ issues. Until relatively recently, she adds, little thought was given to also addressing perpetrators or potential perpetrators in prevention efforts.

As researchers began focusing on college men’s attitudes and behaviors, it quickly became apparent that most of these men didn’t have a clear understanding of consent. In fact, many still believed that, in certain cases, women “were asking for it,” Choate says. Another significant finding also emerged. Although prevention efforts consisting of short-term education programs sometimes temporarily changed men’s attitudes, they did not change behavior. Any lasting change would need to involve long-term education.

ACA member Brittany Talley, coordinator of the Campus Violence Prevention Program (CVPP) at Southeast Missouri State University in Cape Girardeau, Missouri, agrees with that assessment. She has found that although many students — women included — have learned that “no means no,” they don’t really understand that a woman’s decision to consent to sex is completely independent of what she is wearing or whether she has slept with the person in the past.

In the presentations that Talley gives, she also emphasizes that a literal “no” isn’t the only way of communicating that a person doesn’t want to have sex. “We talk about what ‘no’ might [sometimes] sound like — ‘I don’t really feel like it’ or ‘I don’t really want to,’” she says.

Not surprisingly, alcohol is another huge component in many campus sexual assaults. “There is huge misunderstanding about alcohol use and consent. Some students don’t realize that if you are too drunk to drive, you are too drunk to consent [to sex],” says Talley, a provisionally licensed professional counselor.

Talley addresses these myths and misunderstandings in a talk that all freshmen and transfer students are required to attend when they arrive on campus. The 35-minute education session focuses on dating and sexual violence, including how prevalent it is, what constitutes violence, how to get help and how outsiders can help. Talley also hands out cards with a help number and information on what to do after a sexual assault.

In addition to giving presentations and workshops to classes and student groups, Talley has coordinated a number of highly visible awareness events on campus. Part of the goal in these campaigns is to help engage bystanders because she believes that they play a crucial role in preventing sexual assault and violence. For instance, she says, if students at a party or bar notice that someone is being plied with drink after drink, they should step in or get help.

This past fall, the CVPP participated in RAINN (Rape, Abuse and Incest National Network) Day, an annual event devoted to sexual assault education. Most vividly, umbrellas are designed and displayed by participants to draw attention to the issue of sexual assault. The umbrellas can be decorated in any manner the participants wish but must include at least one mention of RAINN somewhere in the design. In addition to making its own umbrella, the CVPP invited various student organizations to submit umbrellas. This was done not only to raise awareness but also in hopes of getting more student organization members involved in prevention efforts, Talley says. On RAINN Day, 20 student organizations displayed umbrellas. Some organizations used serious themes, while others designed their umbrellas as emblems of support. For instance, the group made up of criminal justice students designed an inside-out umbrella because sexual assault turns a person’s life inside out, Talley notes.

The CVPP has coordinated other efforts as well, including the clothesline project, in which T-shirts bearing the stories of survivors of sexual assault were hung up on a clothesline on campus, and “Sexy Time Talk,” in which students lead discussions that focus on the characteristics of healthy and unhealthy relationships.

Only time will tell whether activities such as these will have a significant effect on the sexual assault rate on campus, Talley says. In the meantime, students and staff are reaching out to assist survivors who want help but haven’t been able to take that step, she says.

“One of the most common ways I hear of a case is through other students or a staff member,” she says. “They may ask me to reach out to a particular student, or professors might walk students over or have me come to their offices.” CVPP is part of the university’s counseling and disability services, and in addition to her prevention efforts, Talley counsels survivors of sexual assault.

ACA member Jennifer Sharp oversaw a sexual violence peer education program known as PHREE (Peers Helping Reaffirm, Educate and Empower) at Penn State from 2009 to 2012. “PHREE members worked with the [university’s] Center for Women Students to develop a variety of events designed to support survivors of sexual and relationship violence, provide accurate information about violence and raise awareness,” says Sharp, a national certified counselor (NCC).

PHREE coordinates educational presentations at residence halls and sororities on topics such as dating violence, healthy relationships, sexual assault and consent. It also uses creative, often performance-based events to raise awareness. During Sharp’s time, PHREE members engaged in the university’s participatory theater project, Cultural Conversations, which focuses on social justice issues. PHREE’s performance was on body language. Various participants acted out representative scenarios, and then audience members and performers engaged in a discussion of the issues.

During Sharp’s tenure, PHREE also planned and assisted with activities for sexual assault awareness months that included “survivor speakouts” and poetry/spoken word events that emphasized themes of sexual assault and survival.

Sharp is now an assistant professor of counseling at Northern Kentucky University, where she helped secure a grant to fund the Norse Violence Prevention Project. “The grant essentially provides funding to coordinate and strengthen existing resources for survivors of sexual assault, relationship violence and stalking,” she says.

Sharp is also implementing the Norse Violence Prevention Peer Educator program, which is based in part on the knowledge she gained while working with PHREE. Peer educators are currently being trained to advocate and offer support for survivors of trauma.

Providing services, support and a sense of safety to survivors

Even if the number of sexual assaults on college campuses is reduced significantly, there will always be survivors. Some of those who have experienced sexual violence will seek counseling to help them process and move beyond these devastating events.

Survivors who seek help immediately or shortly after the assault and those who seek help later face many of the same issues, but there are differences in their presenting issues and primary needs, says Sue Swift, a licensed professional counselor (LPC) at the Collins Center, a community center in Harrisonburg, Virginia, that provides mental health, crisis, medical, support and legal services to survivors of sexual assault and violence. The center also uses advocacy and education in its efforts to help end sexual violence in the community.

“When we work with survivors immediately after an assault, we have the primary goal of stabilization and re-establishing at least a basic sense of safety,” Swift says. Establishing safety is especially important in cases of campus sexual assault because the survivor may attend classes, socialize or even live with the person who committed the assault, note counselors who work at on-campus facilities.

When a survivor comes into the Maxine Platzer Lynn Women’s Center at the University of Virginia right after an assault, counselors first determine whether the student’s living situation and general physical environment are safe, says ACA member Charlotte Chapman, an LPC who serves as the director of counseling services at the center. It is also important to start establishing a sense of emotional safety by ensuring that the survivor has a support group or safety net in place.

“A lot of people will say, ‘I don’t want my parents to know,’” Chapman says. “We’d prefer that they use family as a source of support, but that’s not always what they want. … We talk to them about tapping into [support] resources on and off campus.”

Sometimes their best friends aren’t on campus with them, especially if the survivor is a first-year student and hasn’t yet formed strong social bonds, Chapman notes. In such cases, counselors at the women’s center will talk to the student about how to access her or his network of friends through methods such as Skype.

Survivors of sexual assault need help to feel safe because of the range of frightening emotions they are experiencing, Swift points out. “Often, survivors at this stage [immediately or shortly after an assault] are feeling overwhelmed, vulnerable and fearful,” she says. “Counseling can help [survivors] sort through and reduce anxieties [and] develop plans for getting support and taking tiny steps forward.”

“With these acute clients, we might spend a good amount of time normalizing their reactions and feelings but also helping them with grounding techniques and coping skills to deal with the anxiety and stress they are probably feeling,” Swift continues.

Counselors at the Collins Center may also help survivors of sexual assault access resources such as law enforcement, medical assistance and campus services (when appropriate) if they haven’t already done so, she says.

On the other hand, Swift says, survivors who come in for counseling years after an assault are in various stages of distress or healing. Some survivors may seek counseling after a triggering event, while others arrive ready to talk after years of burying their feelings, she says. Regardless of the circumstances that bring them in, these survivors have all had time to tell themselves a “story” about their assault — a story that may include distortions and inaccuracies, Swift says.

“Survivors often blame themselves in some way for what happened or feel badly about themselves,” she explains. “They may feel the assault defines them. Their self-esteem and relationships may suffer.”

It is important for counselors to understand that survivors often have a deep sense of shame. They feel as if the assault was their fault or that they could have prevented it, even when they know intellectually that this isn’t true, say Swift and her colleagues at the Collins Center.

Counselors can be effective at helping survivors of sexual assault work through these feelings, Swift says. She and her colleagues at the Collins Center have found that a supportive approach that allows survivors to set the pace works best. Typically, Swift and her fellow counselors begin by helping these clients to develop coping skills and providing them with psychoeducation about trauma. Most survivors will need help correcting cognitive distortions about themselves and their assault, such as blaming themselves, Swift says. These clients may also benefit from grief work to help them mourn the losses they’ve experienced as a result of the assault, she continues.

“Support groups can also be very healing,” Swift asserts. “Being together in a group, even informally, with others who understand your pain is transformative for many.”

If a client cannot find a support group that offers a good fit, bibliotherapy involving the stories of other survivors can be an extremely helpful alternative, she says. “Many survivors think they are ‘crazy’ until they hear their thoughts and feelings expressed by another survivor,” she adds.

Caution! On campus, confidentiality may not apply

This past January, a University of Oregon student who alleged that several members of the basketball team had raped her sued the university for mishandling her case. Although the players were eventually dismissed from the team and suspended from the school, the survivor alleged that the university had delayed its investigation to ensure the players could remain on the team for the remainder of the season.

As part of a counterclaim — which has since been dropped — the university requested that the campus counseling center release the student’s treatment records.

The incident served as a glaring reminder that counselors who work in campus mental health centers need to ensure that their clients understand that, in certain cases, their records and confidentiality may not be protected. The state of Oregon claimed that it had a right to the student’s records under the federal Family Educational Rights and Privacy Act (FERPA), which allows an educational institution to access student records to defend itself against lawsuits.

“FERPA covers educational records and only educational records. Treatment records for mental and physical health are specifically excluded,” says Perry Francis, who served as the chair of ACA’s Ethics Revision Task Force. However, he explains, the student’s lawsuit in this case specifically mentioned emotional distress, and in Oregon, the law says that if mental health is included as part of a lawsuit, defendants have the right to defend themselves with access to the records. This is an area in which counseling ethics and law collide, notes Francis, a professor of counseling and coordinator of the counseling clinic at Eastern Michigan University.

“Legally, short of a court order, we [the counseling clinic] are not going to release a student’s records,” he says. Counselors do have to follow the law, but before releasing anything, the counselor should discuss it with the student to make sure he or she understands, adds Francis, a past president of the American College Counseling Association (ACCA), a division of ACA. The counselor should also talk to the student’s attorney to discuss what the order specifies and how the counselor or counseling center might limit the information they release. It may be that not all of the records are germane, notes Francis, an LPC and NCC.

M.J. Raleigh, a past ACCA president and the director of counseling and psychological services at the University of North Carolina at Pembroke, confirms there are times when she and her staff have had to release information, but they take actions to limit it.

Anne Marie “Nancy” Wheeler, the risk management consultant for ACA’s Ethics Department, says a counselor who has been asked for a client’s file might be able to provide only a summary of the file rather than the entire file.

“If a counselor receives a subpoena, in many states, the counselor can see if a summary will suffice,” she says. “This is sometimes addressed by state statute, or sometimes the client or counselor can file a motion to quash or a motion for a protective order, which would lead to a court order from the judge. If there is an actual order from the judge, the scope of that order will determine whether a summary or the entire record can or must be released.”

So where does this leave survivors who come to college counseling centers? Raleigh and Francis emphasize the necessity of informed consent for all clients who seek services at a college or university counseling center at every stage of the counseling process, beginning with the intake form. Counselors need to make sure clients understand that there may be circumstances under which the center won’t be able to keep records confidential, they say.

Michelle Wade, an ethics specialist with the ACA Ethics Department, says that counselors who are compelled to release client information should work through an ethical decision-making model. This will help them look at all possible options and outcomes of releasing client information to determine the best course of action that causes the least amount of harm to the client.

“Professional counselors should be aware that they may be called upon to disclose confidential client information under a variety of circumstances, and legal requirements may dictate compliance with such requests,” says Erin Shifflett, director of the ACA Ethics Department. “However, it is imperative that counselors consider their ethical obligations as well. Prior to disclosing any information, counselors should develop a rationale for the disclosure which explores the ways in which the client may be impacted by the release of confidential information and ways to mitigate any potential risks.”

 

****

 

To contact the individuals interviewed for this article, email:

 

****

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

Letters to the editor: ct@counseling.org

 

Addressing fear in child victims of sexual abuse

By Jennifer M. Foster January 27, 2015

One of the most widely published statistics on child sexual abuse, from the Centers for Disease Control and Prevention in 2005, asserts that 1 in 4 girls and 1 in 6 boys are sexually abused before the age of 18. Furthermore, research by John Read and colleagues in 2004 estimated that 50 percent of adult women and 28 percent of adult men who seek counseling have a history of being abused sexually as children. These statistics point to the high probability that counselors, regardless of their practice setting, will encounter child victims and adult survivors of child sexual abuse.

Unfortunately, few counselors have received specific training with this population, and many practitioners report that they are not adequately prepared to provide counseling to trauma survivors. Counselors’ lack of readiness to address child sexual abuse has numerous consequences. These Branding-Box-abuseinclude failing to inquire about the client’s abuse history, failing to provide a therapeutic response to the client’s abuse disclosure, shifting focus due to an inability to hear the details of the client’s abuse and making inappropriate referrals. Additionally, counselors who lack training to work with victims of sexual abuse may struggle to understand the world of the victim or may experience their own countertransference. Lack of training may also increase counselors’ risk for burnout and vicarious traumatization.

The experiences of child victims of sexual abuse

Counselors may have a narrow understanding of the experiences of child victims of sexual abuse due to the limited research that has been conducted with these children. Most published studies focus on the retrospective memories of adults, predominately women. To address this gap, in 2011 I conducted the first known study exploring children’s written descriptions of life before, during and after sexual abuse through a qualitative analysis of trauma narratives.

The analysis revealed a meta-theme, which was titled “Fear and Safety.” All 21 children (18 girls and three boys) in the study reported fears, including during the sexual abuse, during their attempts to stop the perpetrator and during the disclosure. Fear and issues of safety were also present in children’s discussions of their life now (for example, in nightmares and flashbacks) and in their thoughts about the future. A follow-up study in 2014 explored 19 boys’ narratives and confirmed the meta-theme of fear and safety.

Child victims of sexual abuse often view the world as unsafe, and they are likely to enter counseling with unresolved fears. They need help from their counselor to learn how to cope with their fears and how to increase their internal and external resources. Additionally, these children need an opportunity to voice their unspeakable experiences. Because fear is a central part of the child victim’s experience, counselors need to be prepared to implement interventions that address past, present and future fears.

Interventions that target fears

Several treatment models, strategies and techniques are effective in addressing children’s fears related to child sexual abuse, including the following interventions.

Trauma-focused cognitive behavior therapy (TF-CBT) is a comprehensive, evidence-based treatment model developed by Judith Cohen, Anthony Mannarino and Esther Deblinger. It was designed to address traumas and crises experienced by children, including child sexual abuse. According to a meta-analysis conducted by Wendy Silverman and colleagues in 2008, TF-CBT was significantly more effective than placebo and other forms of trauma treatment designed for children and adolescents.

Unlike other models, TF-CBT specifically targets trauma-related fears through a variety of interventions. One of these interventions is the trauma narrative, in which child victims describe in their own words their experiences before, during and after sexual abuse. For those interested in learning more about TF-CBT, a manual titled “How to Implement Trauma-Focused Cognitive Behavioral Therapy,” created by the National Child Traumatic Stress Network, is available at nctsnet.org/nctsn_assets/pdfs/TF-CBT_Implementation_Manual.pdf. Additionally, counselors and counselors-in-training can enroll in a free 10-hour training in the model, available at tfcbt.musc.edu/.

The “safe place” technique is an intervention designed to help children cope with their fears. The strategy can be taught and practiced during counseling sessions so that child victims of sexual abuse can implement it outside of counseling when fears arise. Counselors start by providing information to children (and, if possible, their parents/caregivers) about the technique and how it can help combat fears. Counselors then help children create their own imaginary safe place by asking questions that encourage children to vividly describe their special place.

For example, the counselor may say, “Close your eyes and picture a special place where you feel completely safe.” The counselor then follows up by asking questions that capture additional details, such as “What do you see? What do you hear? What do you feel? What are you doing in your safe place?” The counselor records these details and uses them to create a script.

Similar to other guided imagery scripts, the safe place script often begins with asking children to close their eyes and take several slow breaths. Many children enjoy using the safe place script as a closing ritual to their individual sessions. This can be especially helpful when the sessions have focused on processing their traumatic experiences.

The safe place script can also serve as a springboard into an expressive arts intervention in which children have an opportunity to create their safe place in a drawing or painting or with clay. This extension of the technique may help children better picture and describe their special place.

The comfort kit (also referred to as the “feel better bag”) was developed by Liana Lowenstein in 1999. Its original purpose was to help children who engage in nonsuicidal self-injury to learn self-soothing strategies, but the intervention can be tailored to meet the needs of child victims of sexual abuse by providing them with a tactile strategy for coping with fear.

The intervention begins with psychoeducation for the child (and, if possible, the parents/caregivers) about the technique. Counselors then help children brainstorm and create a list of items that bring them comfort and make them feel better. Although the counselor guides the process, it is the children who choose what will go inside their box or bag.

Common items that children include are their safe place script, a blanket, music, a favorite stuffed animal, guided imagery (either written or recorded), a stress ball, a list of relaxation activities, bubbles (for deep breathing exercises), a favorite book, a picture of a caring person or special place, a journal and pen, art supplies and a list of self-affirmations. Children then select a container that can hold the items they have selected. The child can decorate the outside of the container, and directions on how to use the comfort kit can be adhered to the inside of the box.

Lifeline is an experiential exercise, described in the literature by Maggie Schauer and colleagues in 2003, that provides a creative way for children to tell their story. The idea of talking about their experiences may be especially daunting for children who have been sexually abused. This unique approach helps them begin the process of sharing their experiences in the safety of the therapeutic relationship.

The intervention begins with the counselor providing the child with a long rope that is spread out across the room. Part of the rope will be used, while some at the end will remain unused (this represents the future). Counselors explain that the rope is a timeline of the child’s life and experiences, both good and bad. Some children may benefit from having numbers written on paper and distributed along the line to represent their various ages. The child is then asked to select two types of objects to mark his or her experiences. One of the objects is used to represent positive experiences, whereas the other object represents negative experiences. For example, flowers could mark positive experiences and stones negative experiences.

As children place the objects along their lifelines, they name their experiences. To specifically illuminate children’s fears, the counselor can ask them to mark situations in which they felt fear. Present fears can also be explored. Once children are done marking significant life events and experiences, they can process the experience with the counselor. For older children, the unused part of the rope (the future) can be explored through questions such as: What positive events do you hope to see in your future? What fears do you have about the future?

To preserve the experience, a photograph can be taken of the lifeline. Children can also be given the opportunity to draw or paint their lifelines. This allows the counselor and child to refer back to the lifeline throughout counseling. This may be especially beneficial when past, present and future fears related to child sexual abuse are explored.

Bibliotherapy is an intervention that has a long history of use with children for a wide range of presenting concerns. It is especially relevant for children who have experienced sexual abuse. Children’s books about sexual abuse can introduce child victims to others who have endured similar experiences, which may lead to decreased feelings of isolation and normalize their trauma-related symptoms. Furthermore, books about abuse can provide comfort, teach important lessons (including that the abuse was not the child’s fault) and offer suggestions for coping. Additionally, some books assist child victims in recognizing their internal strength and identifying safe people who can provide them with support.

Because fear is a predominant issue for child victims of sexual abuse, stories that specifically address feeling afraid may be helpful. Once Upon a Time …Therapeutic Stories That Teach & Heal, written by Nancy Davis, provides counselors with several stories designed specifically for children who feel afraid. A Terrible Thing Happened, by Margaret Holmes, a story for children who have witnessed violence or trauma, is another resource for counselors who are addressing fear and its related symptoms with child victims of sexual abuse. The book is written in vague language so that children who have experienced a wide range of traumatic experiences, including sexual abuse, are able to relate with the main character. The Secret: Art & Healing From Sexual Abuse by Francie Lyshak-Stelzer is another book that would be appropriate to help older adolescents explore their memories and current feelings about their sexual abuse. The artwork painted by the author is powerful, and it succeeds in capturing the numerous feelings, including fear, related to abuse experiences.

Summary

Understanding the experiences of child victims of sexual abuse, specifically their fears and concerns about safety, is an important factor in providing effective treatment. The interventions described in this article provide counselors with strategies to help children express and process their fears in the safety of the therapeutic relationship.

TF-CBT provides an evidence-based approach that targets fears and reduces trauma-related symptoms. The trauma narrative, which is a component of TF-CBT, and the lifeline intervention both provide a way for children to share their stories and voice their trauma-related fears. The comfort kit and safe place script equip children with coping strategies that can be used both during counseling sessions and outside of session. Stories about sexual abuse — especially those that address fear, provide education, reduce isolation and give children further opportunity to explore their personal experiences — are also helpful.

Together, these interventions provide counselors with tools that can help facilitate the healing journey for child victims of sexual abuse. 

****

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

Jennifer M. .Foster is an assistant professor of counselor education and counseling psychology at Western Michigan University (WMU). Before joining WMU, Foster worked as a licensed mental health counselor and professional school counselor in Florida. She received her doctorate in counselor education from the University of Central Florida (UCF), where her dissertation, “An Analysis of Trauma Narratives: Perceptions of Children on the Experience of Sexual Abuse,” earned the UCF College of Education Outstanding Dissertation Award. Contact her at jennifer.foster@wmich.edu.

Letters to the editor:  ct@counseling.org

*****

Working with sexually abused children

Gregory K. Moffatt November 25, 2013

BearMateo (not his real name) sat on the floor in my office playroom. Each week in therapy, he routinely played with a small plastic doll and every time, without fail, he placed objects in the doll’s mouth. This day, however, he did something more aggressive. His eyes wide and his face full of rage, he took a Tinker Toy, an apparent phallic symbol, and repeatedly jammed it into the doll’s mouth. “He doesn’t want it in his mouth,” Mateo said into the air, “but he’s going to get it in there anyway!”

A male babysitter had sexually violated Mateo several months earlier. I’m confident, in part based on Mateo’s playroom behavior, that the babysitter had forced himself into Mateo’s mouth. Fellatio wasn’t the only violation forced upon Mateo, but it was the most brutal. Recovery for Mateo would take months.

Those sessions occurred more than 25 years ago. Mateo was one of the first seriously abused children to enter my private practice, and I’ve never forgotten him. Unfortunately, he represents only one in a very long line of abused children I have seen over a nearly three-decade career. In some ways, each child is different, responds to abuse differently and progresses at her or his own pace, but the stages of counseling with this population generally are predictable.

Stages of therapy with abused children 

Stage one: Trust. No matter how much parents tell me their children are shy or “won’t talk to a therapist,” I’ve never failed to gain these children’s trust within the first session or two, often within the first few minutes. More than once I’ve been shocked at how quickly children have divulged deeply hurtful and frightening information to me, almost as though it was ready to explode from them at the first opportunity that someone took to listen. Other times, however, it has not been so easy. Hundreds of children have come through my office doors, and I have learned to use the tools of my trade to create an environment of safety.

Play therapists have an advantage over more traditional counselors in these first visits. My office is full of toys, puppets, books, crayons and sandboxes, along with literally thousands of miniatures. As we begin, my first question is usually “Would you like to play for a while?” Only rarely have I come across a child who didn’t want to play.

I want to give the child as much control as possible throughout therapy, but it is especially important during these first sessions. A therapist I greatly respect taught me the phrase, “You can do about anything you want to in here. If there is something you can’t do, I’ll tell you.” I have used that opening line for years, and it has never failed me.

But children will test that statement. When I said this during Mateo’s first visit, he asked skeptically, “Can I dump all the toys out of the toy box?” He rested his hand on the rim of the large plastic tub that contained many of my toys.

“If you need to,” was my response. As I have learned to expect when such a question is posed, Mateo turned the box up on end and dumped everything out. I sat quietly and smiled at him. He smiled back. I had passed his first test for me.

Mateo called me Greg from our first session. I hadn’t earned my Ph.D. at the time, but even now, I don’t like children referring to me as “doctor.” That term is too easily equated with shots or unpleasant experiences. “Greg” is just fine with me when parents will allow it. That also helps begin to create a context of “us” rather than a view that the child is there to be “treated.”

I have to be very careful how I move when I’m with children such as Mateo. Sexually abused children do not interpret movement in the same way that other children do, especially when that abuse has been repeated over many weeks or months. What most children would regard as an innocuous touch may easily be interpreted by sexually abused children as an invitation or command for sex. In the case of physically abused children, they will flinch if I move too quickly to reach for my pen, scratch my ear or adjust my sitting position on the floor (something I have to do often as I get older). Flinching is an unconscious protective reaction that these children have learned. The quick fists of abusers have surprised them before, so these children learn to be vigilant for punches and backhands. The body remembers.

Stage two: Symptom reduction. Once I’ve built trust with the child, I can begin stage two. During this part of therapy, I want to accomplish two things. First, I want to reduce the negative symptoms that brought the child to my office in the first place. If he or she isn’t sleeping or eating, or is having trouble paying attention at school or getting along with siblings, I work with the child and guardian(s) to address these symptoms.

Mateo regularly acted out sexually. He masturbated in public. He exposed himself to other children on his school bus and in his classroom. Most troubling, he forcibly fondled other children, especially younger girls who were too small or too confused to say no. We had to address these behaviors immediately. I almost always use behavioral modification tools to intervene when behaviors are as serious as these.

The second thing I want to accomplish is to provide the child with skills to manage or prevent his or her issues. I worked with Mateo to recognize his urges and to develop ways to manage them. I have two recliners in my office — one adult sized and one child sized. These are the “thinking chairs.” Mateo and I sat in the thinking chairs, both of us staring at the ceiling.

“I’m wondering what we could do when our body parts feel funny,” I said, referring to the urge to masturbate.

“Maybe I could go to my room,” Mateo said, interestingly turning my use of “we” into “I.” Children are surprisingly intuitive and insightful when adults take the time to listen to them. Going to his room was a good idea — one of many that Mateo came up with during the course of our therapy. When the child discovers a solution, he or she is more likely to believe it will work and, hence, more likely to implement it.

Stage three: Facing demons. Abreaction is a term I learned from Lenore Terr, a writer and psychiatrist in San Francisco. Abreaction means that the child is reliving or replaying the abuse in therapy. We all do this in everyday life. When something significant happens to us, we have the need to talk about it —reliving it through conversation.

Imagine that you saw a car accident happen in front of you on the way to work. You would tell your workmates when you arrived. You would think about it during the day. You might call your spouse and relate the event. This would go on until you had “talked it out.”

Young children don’t have the vocabulary or cognitive ability to talk it out. Instead, they act it out in dramatic play, through the pictures they draw or in the activities they engage in in my sandbox. They literally replay their traumas.

When Mateo was forcing the Tinker Toy into the doll’s mouth, he was abreacting. He was abreacting when he fondled children on his school bus, and his masturbation was also a form of abreaction. Like an interested workmate or an understanding spouse listening to your story of the auto accident, I help children work through their stories over and over until they achieve a resolution.

One child in therapy with me abreacted to a perpetrator by repeatedly burying a little toy man in a wad of play dough each day that we worked together. In subsequent sessions, the child left more and more of the little man uncovered by the play dough. By our last session together, only the toy’s feet remained covered. “I see the man is almost free,” I said to the child. Confidently, the child smiled at me and said, “That’s OK, I can handle him.” This little boy had worked through the trauma of his abduction and abuse. His therapy was almost done.

Stage four: Wrapping up. Once symptoms have abated to a point where the child can cope, when he has the tools to deal with stressors in his life and the invasive thoughts and dreams that haunted him have faded away, the child is ready to work toward closure.

After 10 months of therapy, Mateo’s parents reported to me that his autoerotic behavior was under control and he rarely engaged in that behavior in environments where it was inappropriate. He was no longer exposing himself or talking sexually with other children, and he hadn’t touched another child since our first visit. His abreaction in therapy had trickled into almost nothing. His outbursts and temper tantrums were greatly reduced, and his parents now had the skills they needed to work with Mateo without my assistance. It was time to talk about closure.

Stage five: Termination. Saying goodbye to Mateo was hard for me. When growth happens as it should in therapy, it is rewarding and exciting. It is hard not to take ownership of it, but the truth is, Mateo was responsible for that growth, not me.

In the last session with each of the children I work with, the child gets to choose what we do. This allows the child to have control of his or her final hour with me and the work we have done together.

Mateo selected what many children subsequent to him have chosen. “I want to draw something,” he said.

I nodded but otherwise said nothing. Spilling crayons onto the floor in front of him, he worked intently, drawing on the paper while I watched. I was afraid to move because I didn’t want to break his concentration. When he finished, he took a deep breath, smiled at me and handed me his drawing. Two stick figures were holding hands, the sun bright in the upper part of the page and flowers standing like sentinels on either side of them. One figure looked like Mateo, who always drew himself wearing a baseball cap. The other figure was an adult.

“Tell me about your picture,” I said with interest. But I already knew what he was going to say. It was just what I had hoped for.

“This is me,” he said, pointing to the smaller figure with the ball cap. Then, pointing to the other figure, he added, “… and this is my mom.”

He was ready to go. There would be days in the future when Mateo’s abuse would still haunt him, but for now, he had worked through his abuse, his support system was in place, and it was time for me to say goodbye.

Conclusion

Kids like Mateo are the reason I chose counseling with children as my career path. During my residency and internships, I sat with adults, many of them in their 50s and 60s, while they shared unresolved traumas dating back to childhood. I thought it was tragic that decades earlier, they had been set on a path that permanently affected their lives. Those traumas had set a course for the careers they would choose, the people they would marry and how they would cope with life.

For almost all of these individuals, no one had been there to help them at the time of their trauma. If they had received intervention those many years earlier, their lives would have turned out very differently. My hope for children like Mateo is that the time they spend with me will address issues that, left untreated, could lead to years of dysfunctional relationships and unhealthy habits.

There is nothing more satisfying than working with a child like Mateo. Boys and girls bring their stories to me day after day. The first time they come into my office, they are often broken and fragmented. They sometimes stare at me with wide eyes, wondering if it is even possible to overcome the painful experiences that life has dealt them. Yet at the same time, they are very hopeful and willing to take a chance on me. Most of them leave as completely new creatures. Even though their experiences will always remain with them, I can have confidence that they will not be in a counselor’s office 40 years in the future, crying because of the abuse they suffered. That is something we can take care of now, and that is why each day I face the challenges of this population with courage and hope.

Click here to read Gregory K. Moffatt’s related article on complications related to working with sexually abused children. In the article, he discusses confidentiality and mandated reporting, hidden agendas, assessment versus therapy, evidence-based therapy, preparing for court and staying healthy as a counselor when working with this population.

****

 

Gregory K. Moffatt is a licensed professional counselor and professor of counseling and human services at Point University in Georgia. Contact him at Greg.Moffatt@point.edu.

Letters to the editor: ct@counseling.org