Working with Adult Survivors of Child Sexual Abuse

Elsa Jones

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367104603
• eBook ISBN: 9780429924255
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The author, working from the Family Institute in Cardiff, has been treating adult survivors of child sexual and physical abuse for several years, and she has clearly and frankly described her work in this book. She begins be describing the context for working with her clients; then describes the way she has welded systemic thinking and a feminist perspective into a theoretical model she uses to understand the problem and to guide her own work with the survivors. The descriptions of the therapeutic process are, at the same time, profound and simply conveyed. Her work is further clarified by the inclusion of twenty case examples. She shares her own dilemmas about working with adult survivors, and in this way the book offers the reader support for the emotional impact of this work as well as a theoretical framework and suggestions about therapeutic technique.

Part One
Setting the Context

Chapter One
Background

The guidelines that are offered in this book were first proposed by myself and my then colleague, Bebe Speed, to help us think about work we were currently doing with women clients who had been sexually abused as children. These ideas have been refined and elaborated over the ensuing years as a result of feedback from workshop attenders and clients.

There is now a wide and constantly proliferating literature on sexual abuse, ranging from theory and research, to work with the families of children where sexual abuse has been disclosed or is suspected, to survivors' own accounts. My own work is firmly based on the experience and knowledge of the many other contributors to this field (of whose work only a small selection is cited in the bibliography). The knowledge accumulated by those working with the disclosure, management, and therapeutic response to the sexual abuse of children forms the bedrock on which workers with adult survivors rest their understanding of the likely experiences and effects for their own clients. While there are—and probably always will be—differences of interpretation and emphasis amongst those writing about sexual abuse, there is also broad agreement, particularly amongst those working therapeutically with abused children or adults, about the kind of helping approaches that are found useful by such clients. As Hall and Lloyd (1989) and Trepper and Barrett (1989) point out, books about therapeutic approaches (as opposed to theory) are in a minority; it has therefore seemed worth-while to contribute my own ideas about ways of working with survivors.

These ideas are offered here, not as expert or prescriptive statements about the situation of abuse survivors, or about how they should be worked with, but purely as ideas which may offer a helpful structure for the thinking of those working in this area. There are two reasons, in particular, why I would not claim to be making an "expert" statement, and these will be discussed separately below.

1. A Systemic Perspective

In the course of my teaching I all too frequently meet workers, particularly in social services agencies, who are carrying enormous case-loads of abuse work, both current and with adult survivors. It is not uncommon for such a worker to have 50 cases currently on her files. The sheer volume of this work, and its frequently distressing nature, makes it unsurprising that such workers should feel overloaded, depressed, and useless—in other words, "burnt out". In addition it is now a truism in systems thinking that professional systems often replicate the organization and characteristics of the client systems with which they work. Thus professional systems set up to deal with sexual or physical abuse can easily develop into "abusive systems", where the worker is at the receiving end of the enormous social anxiety generated by the dawning realization of the extent of abuse in our society. Such a worker will be expected to function, with no margin for error, under circumstances where her case-load is too large, where she is expected to make "life-or-death" decisions without time to think or consult, and where the media and her own hierarchy are, from her perspective, waiting to blame her for any error of judgement. She will feel abused, and her professional and personal values, her concern for clients, and her position within the hierarchy will render her voiceless, so that she is liable to blame herself for whatever goes wrong, as well as for her own unpleasant emotions. This replicates the situation of the victim of abuse.

My work in the Family Institute in Cardiff (F.I.), which will be discussed in more detail below, means that I work with abuse survivors among a range of other clients. I am therefore not an expert in abuse work, in the sense that the hypothetical worker above could be said to be, since she will have seen many more abuse survivors than I have. However, working within the team context of the Institute, and within the framework of systemic therapy, means that there is space and time to think about the problems that clients bring to therapy, which without such support can seem overwhelming. Based on this experience, it is my conviction that using the theory and skills that derive from a systemic family therapy approach is appropriate to work with abuse survivors, as with many other kinds of problem-definitions or problem-determined systems, and that thinking systemically can enable us to work with adult survivors in a way that is likely to lead to a sense of empowerment for clients and workers.

2. "Experts" Create Problems

The second reason why I am reluctant to set myself up as an "expert" in work with abuse survivors is that the existence of such "expertise" would imply that having been abused as a child constituted some sort of category or syndrome, which was necessarily a source of difficulties, and which required the attention of an "expert". I agree with Durrant and Kowalski (1990) that the assumption that abuse survivors can be fitted into categories, are necessarily "damaged", and require therapy on which we are the experts, constitutes "a stance that requires clients to submit to our prescription of their experience and [we] have come to view such a process as oppressive and as potentially perpetuating the effects on self-view of the abuse itself" (p. 69). A great deal of work has been done in the attempt to define sexual abuse (and definitions differ depending on whether they emanate from abuse survivors, from mental health professionals, or seek to clarify legal categories); to establish how widespread it is; to determine whether its effects are always negative; or to discover what protective factors may be available for some abused children as compared with others. For extensive and sometimes widely differing discussions on these issues, see for example La Fontaine (1990), Hall and Lloyd (1989), Bentovim et al. (1988), or Finkelhor (1984). Until we know far more than we do at present we will not have any certainty about the incidence of childhood abuse, whether sexual or other, or of the complex, subtle, and wide-ranging consequences of having been abused. What we can do in the meantime is to work with the experienced effects of abuse, and to take the client's word for what these are.

I shall in the rest of this book discuss some patterns I and others have observed in our work with survivors. Because of the foregoing it should now be clear that these ideas are guidelines and not blueprints or prescriptions.

3. The Work of the Cardiff Family Institute Team

a. Working style

The Family Institute is part of the work of Barnardos in Wales and the South West of England; it is therefore not within the Health or Statutory Services, and this fact has many implications for how this team works as compared with others. The Team consists of five family therapists and two administrative secretaries. The family therapists, who come from different professional backgrounds, work as a peer team, earn the same, and share the work of the team on a rotating basis, including the job of being Chairperson of the Institute.

The major family therapy influence on the way the F.I. team works has been the therapeutic orientation of Luigi Boscolo and Gianfranco Cecchin of the Milan Centre for the Study of the Family. We are part of a network of continuously co-evolving family therapists, which includes the two Milan men, and which is sometimes referred to as a "Post-Milan" orientation. What this means, broadly speaking, is that since the publication of the Milan group's first book (Selvini et al., 1978) numerous family therapists and teams have been taught and influenced by their way of working. In turn these groups have influenced each other as well as those members of the original Milan team who, via their teaching and consultation, have maintained links with their former trainees. This loosely linked group continues to explore the implications of new ideas, and feedback from clinical work and teaching, for both theory and practice. I shall also discuss the influence of feminist therapy and feminist critiques of family therapy on our work.

Fundamental to our work are assumptions about the way in which individuals or groups form part of evolving systems in which each individual member influences and is influenced by others. We see the therapists as participating in these systems of mutual influence, mutual search for the co-construction of new meaning, and mutual search for the possibilities of change in action or meaning. Since this is not a handbook of systemic therapy I shall not here elaborate on the complexities of theory and practice, but will illustrate the particular application to work with abuse survivors in the chapters that follow. Readers new to this way of working are referred to the reading list at the end of the book, in particular Hoffman (1981), Campbell and Draper (1985), Selvini et al. (1978), Cecchin (1987), and Jones (in press). However, I shall attempt a brief statement about some of the major components of my therapeutic orientation as a background to the work that follows, while hoping that the necessary brevity of this statement will not lead to misunderstanding.

As a therapist I assume that when someone approaches me for help with the difficulties they are experiencing these may be linked to factors both in their past and in their present, and may have individual and "internal" components as well as interactional and contextual ones. I assume that there is a looping relationship between action and meaning, so that a change in behaviour may well lead to the attribution of different meaning, just as a shift in the assumed meaning of events may lead to changes in behaviour. I assume that each individual has resources and strengths, no matter how despairing they may be feeling at the moment of coming to therapy, and that it is my job to help them find access to these, without minimizing the seriousness of the troubles by which they may have been overwhelmed. I also assume that people themselves have a better idea of their own history, values, creative resources, and what solutions are likely to fit for them, than any outsider can ever have, so that the therapist's task is, as it were, to help clients roll obstacles out of their path, but not to point out the route they should be following. At the same time I am aware, on the basis of theory as well as observations in therapy and in my own life, that it is difficult to attain an overview or meta-perspective on one's own situation, so that sitting down to talk with someone else, whether a professional therapist or not, may be necessary in order to begin to look at events, connections, and previously obscured aspects of the patterns of action and relationship that accumulate around "the problem". I therefore assume that I am unlikely to know the answers to clients' dilemmas, but that my systemic curiosity, my technical skills (e.g. in asking circular or hypothetical questions), my respectful search for their own skills and resources, my widening of the area of inquiry to include wider contexts that may previously have been left out of account, my challenge to set ways of thinking, and my attempt to create a safe and containing space in which the unthinkable and unsayable can be expressed, will have the effect of freeing up the client's own ability to explore, to grow, and to resolve dilemmas. As one client couple said to me: "Coming to sessions is fascinating: something about the way you ask questions means that we keep opening new doors that we thought weren't there." In summary I might say, then, that the therapist's major task is to introduce "news of difference" (Bateson, 1980)—that is, flexibility, complexity, options, different perspectives—into the therapeutic conversation with the client, so that the experience of being stuck and having no choice can change into one of feeling freed up to create one's own preferred new ways of relating to self and others.

What I don't assume should be implicit in the above: I do not assume the presence of pathology, with all that that concept implies about illness, defect, and the superior ability of the professional to see what is wrong and therefore to diagnose and label the client. I do not assume that it is possible to interact instructively: that is, although I may have the intention that clients should do such and so, or should interpret my words as such and so, what they in fact do with these will depend on their own history, beliefs, and values, view of the relationship with me, meaning-attribution, and so on. I do not assume that clients who do not behave in the way I expect them to, are "resistant"—instead I wonder what I may be doing to make them feel as if they've been backed into a corner, and I try to respect and understand their own style and pace of change. I assume that most people when they experience difficulties, myself included, are keen to change and anxious or fearful about the—sometimes unknown—consequences of change. I do not assume that all grief, pain, and injustice can be ameliorated, but that we may have some degree of flexibility as to the stance we adopt towards them, and that the choice of stance has implications for our well-being.

When working with clients, then, I would want to understand the difficulties and dilemmas that bring them to therapy, as well as the contexts in which these arose and are maintained, and the meanings attributed to them by the clients themselves and by others who have or have had an influence on them, such as family, friends, colleagues, or mental health professionals. While I know that the mere act of talking to someone who listens non-judgementally, and hears accurately, can be a great relief, I do not subscribe to the view that ventilation and catharsis are necessarily therapeutic, or have to precede any significant change. Therefore my focus in therapy will always be in the direction of difference, and I will be attending to the client's own descriptions of the differences they have been able to make in the past or the present to their own circumstances, as well as attempting, particularly by the use of future-oriented questions, to explore what differences may potentially occur. When a person explores hypothetical future scenarios in their own lives and those of others, the act of imagining these already alters the sense of "stuckness", in which previously no alternatives seemed possible.

I will also work in a way that attempts to empower clients. Since this is a fashionable word these days, it is necessary to explain my interpretation of it, which rests on views on the nature of the therapist/client relationship first articulated by feminist therapists (e.g. Gilbert, 1980). In order for the therapist not to abuse power it is important for her to accept that at the beginning of therapy there will be a power imbalance between herself and the client. This is because the client is the one who is seeking help, is probably feeling vulnerable and anxious, and is unsure of the "rules of the game", while the therapist is on home ground (in the sense of being familiar with the "rules" of therapy), is not participating in the therapy in order to talk about her own vulnerabilities and difficulties, and is armed with technical expertise and skill. The therapist should continue to take responsibility for the professional knowledge and experience she carries, and which she should be using and, where appropriate, sharing to the benefit of the client. She should also do all she can to shift the relationship in the direction of an open sharing between equals who are engaged in a joint venture, what Eisler (1988) calls a "partnership model".

The F.I. therapists normally work with a team and a one-way screen, as well as a videotaped record of the session. That is, the therapist is in the room with the client or clients, and one or more team members are behind a one-way screen from where they observe the therapy session, and offer comments to therapist and clients to enhance the therapeutic work. This arrangement can, of course, only be used with the permission of the client. This way of working, and its rationale, are carefully explained to clients when they first enter the room. Working in this way has proved extremely helpful to systemic therapists; therapist and clients are seen to benefit from the support and wider perspective thus obtained.

Many abuse survivors are uneasy with the presence of unseen observers, for good reasons to do with their experience, e.g. of powerlessness or of actual voyeurism. We would be particularly alert to this possibility when proposing to work with the team and with video recordings. On the other hand, some clients who have been abused welcome the presence of the team, as they regard this as offering some protection against further abuse within the therapy setting, because of the "visibility" of the therapist's work. If the client is uneasy about any aspect of our usual arrangement we would discuss a number of alternatives, ranging from no videotape, to meeting the team members who then return to their position behind the screen, to working with one team member offering live consultation in the room, to working with no team consultation at all. The case examples that are discussed, in disguised form, in this book all derive from work with clients who have given written permission for their material to be used for teaching purposes.

Our usual working format consists of brief sessions (on average between two and ten) with intervals in-between sessions ranging from one week to several months. By preference we would work with as many family members as are willing to attend sessions, together with, where relevant, other significant people such as friends, neighbours, or professional workers. When working with adult survivors we have found it necessary to combine individual meetings, that is, one-to-one therapy with the survivor, with sessions including a variety of others from the survivor's family of origin and current family. This is because much of the work requiring to be done is particularly personal and private to the survivor herself. Much of our work with survivors tends to be longer-term than our usual family therapy practice. It may be that this is because of the way in which the effects of childhood abuse tend to be intertwined with, and organizing of, most aspects of the survivor's life; on the other hand it may be due to the nature of individual therapy itself, and the therapist's assumptions about the slower pace of such work.

b. Clients

A majority of the F.I.'s clients are self-referred. This means that they have heard of us through friends or family who have consulted us before, or have learnt of our existence from professional or community sources. The rest of the clients come to the F.I. via the usual professional referral sources. In the last few years we have seen a great upsurge in the number of adult abuse survivors coming to consult us. I know that this trend is also reflected in the work of other agencies.

Initially the majority of abuse survivors first approached the Institute in relation to problems other than those of childhood abuse, e.g. problems focused on their children, such as disciplinary issues, anorexia, or worries about over-protecti...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• EDITORS' FOREWORD
• FOREWORD
• INTRODUCTION
• PART ONE Setting the context
• PART TWO Guidelines
• PART THREE Some questions and dilemmas
• NOTES
• BIBLIOGRAPHY
• INDEX