Counselling sexual abuse survivors Some nurses are notv becoming involved in helping

ship is inherently good or bad, may readily

Advanced Diploma in

adult survivors of child sexual abuse to overcome

accept the development of a sexually abusive

Counselling, is Nurse/AIDS

problems caused by an early abusive relationship.

relationship. The relationship can validate her

Adviser, AIDS Counselling and

Developing a therapeuticpartnership between victim

basic sense of grandiosity, ie ‘the expectation

Training Service, Worthing

and counsellor is a fundamental part of resolving

that all needs will be gratified by the caretak­

District Health Authority.

such problems. Using a psychodynamic perspective,

er’ (3); or its presentation may allow it to be

the author examines the effects ofchild sexual abuse

seen as an extension of an affectionate, loving

on female survivors, and discusses the benefits of


Christine Daniel BSc Hons, RON,

group therapy and individual counselling in help­ ing the survivor to come to terms with the abuse.

The child will accept the adult’s definition of events because of her dependency needs; to see the parent as bad will provoke feelings of

Child sexual abuse (CSA), after years of a

abandonment and annihilation, which may

shadow existence, is finally receiving a much

also be reinforced by real threats.

needed focus. Statistics in the United States

In contrast to the security required by the

suggest 43 per cent of women have experi­

child, the secrecy surrounding the situation

enced an unwanted sexual encounter before

will communicate a sense of danger - of fear­

the age of 13 (1). Its long-term effects will be

ful outcome. Thus, to reconcile the ‘good’

dependent on the initial circumstances and

parent with the‘bad’ behaviour, the child may

handling of the abuse.

split good from bad. To preserve the parent as

When initiating a therapeutic relationship, the adult survivor of CSA is embarking on a

‘all good' she or he becomes idealised, and the child internalises the bad.

long journey, the success of which will again

The child will also experience strong and

depend on the handling of the abusive rela­

intense feelings of guilt, rage, horror and fear, the expression of which may result in parental

tionship, this time by the counsellor. This article looks at the effects of CSA from

abandonment. To protect the developing ego,

a psychodynamic perspective and focuses on

the child may repress her feelings, disassoci­

treatment issues in the context of group ther­

ating them from her experience.

apy and individual counselling. The definition of child sexual abuse I shall use is: ‘The exploitation of a child for the sex­

Overwhelming anxiety

ual gratification of an adult, with exploitative-

The impact of CSA is crucial at any stage of

acts defined as: genital fondling (of child and

development but the younger the child, the

adult); penetration (oral, anal or vaginal) and

less developed her ego, and the less she is able

rape’ (2). The psychodynamic process describ­

to make sense of these events. The child’s for­

ed will be that of the female; social factors have

mation of a ‘cohesive self will be disrupted

the potential to create a different process for

and ego development may be blocked at a primitive level. As she moves through later

the male. The early experiences of a child are seen as critical to the psychic structure of the person­

ma(s) may be reflected at new levels.

ality, with the early dependency relationship

Consequences of child sexual abuse Psycho-

between caretaker and child having a major

dynamically, the most important impact CSA

influence in personality development. It has been suggested that a child’s reaction


has on the child is that of an overwhelming anxiety. Defence mechanisms will be used to

to sexual abuse will depend on her psycho­

protect the developing fragile ego from these


anxieties. Whichever mechanism

stage of development


For the

young child, the experience of her caretaker


developmental milestones, the original trau-

the child

evokes will be dependent on many variables,

can be idealised and perceived as an extension

including type of abuse, and the age and char­

of herself, because of the caretaker’s capacity

acteristics of the child.

to fulfil the chi Id’s strong drives and emotions.

The young child, as suggested above, is

Consequently, the child, who does not have

likely to cope by repression and dissociation,

the skills to distinguish whether a relation­

resulting in the fragmentation of self into

28 .Nursing Standard August 5 Volume 6, Number 46/1992


‘Although many sexually abused women describe symptoms of anxiety, depression and relation­ ship problems, all are experienced with differing degrees of intensity and dysfunction ’


good and bad parts. Dissociation can present with the child splitting from her emotions, cutting off her feelings in relationship to oth­ ers and, at the severe end, ‘switching off (2). An older child may learn to dissociate through the misuse of drugs and alcohol. The child’s ability to repress these experiences may extend to the adult’s complete inability to remember the traumatic event(s) altogether. The source of problems in adulthood will be out of her awareness; 'problems’ may present in psychological form or result in psychoso­ matic disturbances, in which the body expresses the original psychological trauma. An older child may also internalise herguilt and anger, which can become expressed in the form of self-destructive behaviour such as selfinjury, suicide attempts, depression and eating disorders. Externalisation may be artic­ ulated in delinquency or crime. Central to the sexual nature of the abuse will be the effect on the psychosexual development of the child. More generally, the child will have suffered, in an incestuous relationship, a basic lack of ‘psychological nourishment’ necessary for the development of a healthy personality. The child’s unfulfilled dependency needs, repressed emotions, and lack of basic trust, emanating from the abuse, will form the bases of later problems in adulthood. Group therapy Herman and Schatzow (4) sug­ gest that group therapy is the treatment of choice for addressing the interpersonal prob­ lems of the incest survivor. They see it as a recapitulation of the family experience, and as having special relevance for the problem of incest. Alexander and Follette (5) state that a time-limited group format is particularly ger­ mane to the problem of incest because of: • The specific focus on incest, which counter­ acts the incestuous family’s denial of the problem, and alleviates the sense of stigma resulting from the abuse experience • The clear time boundaries that provide a contrast to the lack of structure in the inces­ tuous family • The resulting decrease in the incest sur­ vivor’s sense of isolation, which can allow interpersonal experimentation with more adaptive attitudes and behaviours. Alexander et al (6) produced evidence for this in a study in which group treatment was shown to be effective in reducing depression and alleviating distress in women who had been sexually abused by a father, step-father, or other close relative. This study was similar to most other therapy outcome studies in not finding differences between types of group treatment (7).

In group therapy formats, there will always be a variability in outcome among group members. In this context, it is important to recognise that although many sexually abused women describe symptoms of anxiety, depres­ sion and relationship problems, all are experienced with differing degrees of intensity and dysfunction.

Maximise benefits With this in mind, Follette et al (8) evaluat­ ed 65 sexually abused women who participated in time-limited group therapy before treatment. The study aimed to identi­ fy variables that correlate with long-term adjustment before therapy and to examine their influence on the women’s response to group therapy. Following a comparison between the vari­ ables established in the evaluation, and treatment response, the following factors appeared as predictors of treatment response: education; marital status; type of sexual con­ tact; initial levels of depression and distress, and history of previous therapy. Follette et al conclude that within group therapy it may be possible to modify and supplement aspects in order to maximise the clinical benefits for the participants. Individual therapy, either before or concurrent with group work, is one possi­ ble adjunct. The counselling process In view of the diversi­ ty of experiences held by survivors of CSA, and the subsequent complex long-term psycho­ logical effects, clinicians have presented the following guidelines: • Treatment should be based on the issues raised by the nature of the experience and on the survivor’s unique response pattern (9) • The tools and techniques together should reflect a comprehensive approach that takes into account the cognitive, emotional, physi­ cal and social problems of the individual (10). Thus, treatment must be tailored to meet the particular needs of individual clients. Adult survivors of child sexual abuse do not form a homogenous group and individual clients will present with their own personal set of problems. Certain factors are important, however, if the counselling process is to have a chance of success. For some clients, counselling may have been initiated before a woman’s aware­ ness of her CSA; at any stage she may disclose. It is imperative that this initial disclosure is a positive experience; both the woman and her internalised child need to express their feel­ ings cathartically and have them validated. If the counsellor views the client’s story as August 5/Volume 6/Number 46/1992 Nursing Standard 29


References 1. Finkelhor A. A Source Book On Child Sexual Abuse. London, Sage. 1986. 2. Osborn J. Psychological Effects Of Child Sexual Abuse On Women. Norwich, University of Hast Anglia. Social Work Monographs. 1990. 3. Kilgore L. Effect of early childhood sexual abuse on self and ego development. Social Casework. 1988. 69, 224-230. 4. Herman J, Schatzow E. Time limited group therapy for women with a history of incest. International Journal of Group Psychotherapy. 1984. 34, 605-616. 5. Alexander P C, Follette V M. Personal construct in the group. Treatment of incest. In Neimeyer R A, Neimeyer G J (Eds). Personal Construct Therapy Casebook. New York, Springer. 1987. 6. Alexander PC et al. Comparison of group treatments of women sexually abused as children .Journal of Consulting and Clinical Psychology. 1989- 57,4,479-483. 7. Kaul T J, Bednar R L. Research on group and related therapies. In Garfield S L, Berg in A E (Eds). Handbook of Psychotherapy and Behaviour Change. New York, Wiley. 1986. 8. Follette V M et al. Individual predictors of outcome in group treatment for incest survivors. Journal of Consulting and Clinical Psychology. 1991. 59, 1,150-155. 30 Nursing Standard August

fantasy, the unheard feelings can only become internalised with secondary and pervasive chronic responses developing. Many clients feel shame and guilt after dis­ closure to the therapist, and feel compelled to escape. Trusting the counsellor is a major issue for the client. For these reasons it is important to establish a commitment to therapy and to engage the client as much as possible. This promotes the development of a rela­ tionship, in which the client can feel a measure of control and responsibility, and counteract her inclination to flee therapy (11). Cahill also suggests that the identification and the subsequent discussion of patterns in a client’s behaviour may also be useful in enabling the counsellor and client to identify these phenomena as they arise in the thera­ peutic relationship. This facilitates involvement on the part of the client in the therapeutic process. Case example Mary (an adult survivor of CSA) would, when under stress during a counselling session, start to daydream or walk over to the window and gaze out. By my reflecting back this process to her, Mary has gradually been able to recognise her actions as an attempt to flee from the session. The maintenance of trust will remain an ongoing issue, which may be periodically test­ ed by clients. Mary will occasionally ‘dangle’ an event before me, which she will reveal dur­ ing the session only if I appear to be trustworthy. During supervision I have described these sessions as 'being in a boxing ring’. To withdraw attention for a short while allows the punch to be thrown; I am untrust­ worthy. When this happens, 1 find 1 am sharing the rest of the session with an angry and hurt young child. Reflecting back on this process each time it occurs is important if the counselling is to move on. The degree of importance placed on the client relating details of the abuse varies between therapists. Although many see it as necessary, even crucial, Jehu (12) says ‘it is the psychological meaning of the abuse to the survivor that needs to be explored, more thor­ oughly than the physical acts’. Gelinas (13) states: ‘Incest occurs within the family, within a context that is “supposed” to nurture, protect and care for the child, where she should be able to get a reasonable interpretation of reality and relational life and upon which she is utterly dependent. Incest is a profound abandonment and betrayal, trav­ esty of the parental love and care that is a young child’s inherent right. ‘But the child grows up inside the incestu­ ous system with no perspective, no language,

5/Volume 6/Number 46/1992

and with no experience base with which to stand outside these relational and sexual forces, and form a healthy personality and set of relational templates uncontaminated by incest.' In this context the counselling process can only be very slow. A woman who is dis­ covering the shadowed side of her upbringing may be extremely fearful of what she may find, and so the importance of the counsellor’s abil­ ity to hold these sessions cannot be overemphasised. Smith (14) stresses that approach and pacing are extremely important, and before work begins on repression, denial and emo­ tional avoidance of che original trauma, counsellors should work with the client on coping mechanisms for reducing the anxiety, stress, anger and fear which such recollections may induce.

Calming influence For Mary, this was achieved by writing poet­ ry or prose when the fears seemed to overtake her at home; sending the script to me appeared to initiate a calming influence. Regardless of orientation, most counsellors and therapists agree the dynamics of abuse and complexity of personal issues that arise from CSA require long-term work. The client needs time to claim back what is rightfully hers, in terms of her body, her feelings and the right to express herself. The counsellor’s role must be to help ‘de-confuse’ the client’s inner child, and to help her to reorientate as an adult, slowly coming to the realisation that she no longer has to sell her­ self in order to be loved. The counselling environment needs to be one where the client can feel safe, accepted, acknowledged and loved. Bigras (15) states that early in the coun­ selling relationship there is unlikely to be any transference between counsellor and client. Any acting out may well be occurring between the client and her partner. As the counselling relationship develops, however, the counsellor’s potential for control and power can easily lead to a recreation of the client’s childhood experience of being totally out of control. For the client, this may pro­ duce a ‘repetition compulsion' to recreate within the transference the same feelings and situations experienced as a child, and could easily result in a re-enactment of an abusive relationship. This is the difficult part; for the counsellor it involves the need to be alert to the client’s unconscious perceptions of him or her as destructive and abusive. The client will usu-



Mental health: counselling sexual abuse survivors.

Some nurses are now becoming involved in helping adult survivors of child sexual abuse to overcome problems caused by an early abusive relationship. D...
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