Psychotherapy with Survivors of Sexual Violence

Inside and Outside the Room

Erene Hadjiioannou

• Publisher: Routledge
• Year: 2021
• eBook ISBN: 9781000433302
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The role of psychotherapists in creating change for survivors of sexual violence can extend far wider than the rooms in which appointments are provided. Psychotherapy with Survivors of Sexual Violence aims to provide psychotherapists with practical guidance that will enable them to work with the prolific societal issue of sexual violence, both in the privacy of clinical practice and the wider world as activists.

Erene Hadjiioannou outlines the components of relational psychotherapy necessary to counter the trauma that brings survivors to services, with a particular focus on empowerment and the freedoms that constitute it. The book defines the neurophysiological systems involved in surviving traumatic experiences and common psychological presentations, including post-traumatic stress disorder.

Hadjiioannou explains the long-standing challenges of delivering psychotherapy to survivors who have reported to the police from various perspectives: understanding the criminal justice system, note-keeping, and survivors' experiences of reporting. Barriers to accessing support, including myths, are examined and the book includes interview quotes from a range of survivors as well as fictional case studies throughout.

Psychotherapy with Survivors of Sexual Violence will be a key text for psychotherapists of all backgrounds working with survivors, and for mental health professionals in training.

Chapter 1

Sexual violence in context

DOI: 10.4324/9781003202943-1

Contextualising our shared dialogue

The intention of this book is to better enable psychotherapists to respond to the needs of survivors of sexual violence via traditional appointments, varying types of psychotherapeutic work in community spaces, and supportive action in the wider world whether one refers to this as activism or by any other term. Furthermore, this book aims to demonstrate how to: alleviate the traumatic impact of sexual violence, increase accessibility of psychotherapy to all survivors, become allies to the process of recovery in public spaces, and collaboratively create social change around an issue that is profoundly disempowering.

There is much to consider in contextualising the dialogue around sexual violence wherever such dialogues occur. The purpose of this is primarily to ensure that all parties understand the nuances of a very complex societal occurrence and its impact on the clients we meet in psychotherapy services. It is also true that sexual violence occurs globally on a prolific scale, meaning that a shared understanding is something to constantly be asserted and re-asserted in service of supporting survivors impacted by it.

The value of lived experience in clients and psychotherapists is vital in evolving our profession, as this is first-hand information gathered from having lived through sexual violence rather than it being known purely theoretically. Such truths can include experiences of disclosure of sexual violence to others in various spaces and trying to access personal or professional support, as both can have positive or adverse effects on the individual. This includes psychotherapy as a space within the wider world.

We can start by contextualising our dialogue as professionals and work towards expanding it outwards to join the global conversations about sexual violence. This back-and-forth process means that our professional language, and therefore how we understand this phenomenon, will change over time. The influence of the internet as a space in the wider world that we each occupy can mean such changes occur much faster than prior to its existence. It also means that the voices of individual survivors can be heard more easily as part of a wider movement of empowerment and change.

Within psychotherapy any words a client uses to refer to their experiences should be respected via the mirrored use of them by their psychotherapist wherever possible. A chosen use of language is a part of finding one’s way in their process of recovery. Psychotherapists can then begin to meet individual survivors and honour their subjective lived experiences, in ways rarely found elsewhere within a society that wishes to ignore or further persecute them especially when they speak.

Being survivor-led means integrating survivors’ truths into professional practice, and the language used in this book is influenced by this principle. The psychotherapeutic working relationship thus includes being allied with such clients, which involves having professional dialogues directly influenced by subjective accounts. Within psychotherapy this is powerful to the process of change in the client’s life and this power can reverberate further into the field too.

This perspective on language also acknowledges that every survivor will use specific words, including naming different types of sexual violence, differently. Sadly, the configurations in which this issue occurs are numerous and varied. Discrepancies in language between survivors can denote a use of words to avoid re-experiencing what happened whilst still needing to refer to it and knowing that words are shaped by cultural understandings of sexual violence. Additionally, there are often disparities between how words are used in the subjective process of psychotherapy versus the more objective arena of the legal system or any other formal process of disclosure.

There are several words and phrases to qualify in order to begin a dialogue of this kind, with all its nuances. In this book ‘sexual violence’ is an umbrella term that points to the wide range of non-consensual sexual contact a person can experience in their lifetime. The word ‘violence’ is included to denote that such contact is always violating, although it may not be stereotypically or overtly violent. Furthermore, such violence refers to the kind of forced re-organisation of the self, the intrusion into one’s psychological (mind) and physical (body) facets of this self, and the subsequent interruptions to the many domains of one’s life.

The impact of sexual violence is often referred to as ‘traumatic,’ including in everyday conversations. Although a direct nod to diagnostic criteria that can theoretically help psychotherapists understand a client’s difficulties, it is true that the personal result of sexual violence does not always come under this category upon professional nor personal evaluation. However, within this book this term is used in order to provide a recognisable broad understanding of the degree of psychological, physical, practical, and relational injuries caused by sexual violence.

Interweaving theory, practical action, case studies of fictional clients, and lived experiences of real survivors within this book reflects the process of relational psychotherapy. Relatedness is not a linear act between selves and is definitely not the case when trust is disrespected through sexual violence. When any of us relate our selves become visible and become open to receiving other selves in a tangible way. Such visibility can be felt as threatening to the survivor, including to the extent of putting their life at risk, which is why many psychotherapists only meet certain facets of their client’s selves.

As relational psychotherapists we aim to meet the person amongst their presenting concerns. We simultaneously aim to enable clients to safely meet all the facets of their self they are disconnected from because of the impact of sexual violence. These meetings are places where the balance between theory and experiential work, characterised by the relationship, occurs within a co-created psychotherapeutic conversation.

At each contact point in the process of relational work psychotherapists and clients make psychological contact with each other. This includes influencing each other’s subjective experience at conscious and unconscious levels. Such influencing occurs even when clients are so highly traumatised that they cannot safely engage with the working relationship on a consistent basis, as is the case for many survivors.

Furthermore, influence between selves is not only necessary for effective psychotherapy to take place. It also assists in evolving the profession along with society as we all better understand the impact of sexual violence wherever and however it manifests. A psychotherapist making space for the truths of survivors is inherently vital for therapeutic work and is a mark of commitment to being an ally to this often societally persecuted population.

In the spirit of being allied the words ‘client’ and ‘survivor’ are used interchangeably. Both reflect the ever-changing nature of language in public and psychotherapeutic spaces. ‘Survivor’ in particular is a reflection of widely-accepted vernacular within movements led by those with lived experience and support services at the time of writing.

The use of ‘survivor’ is also relevant to the overall ethos of the explorations outlined across all chapters as a way to signal empowerment to those who have endured traumatic events, as well as finding ways to live long after these take place. This is in comparison to ‘victim,’ another commonly-used term, although some clients may resonate more closely with this word at times.

In a book where the legal process is discussed as an overlap to the psychotherapeutic process, using ‘survivor’ provides a linguistic distinction from the former in practice and experientially. Many clients are re-traumatised by the criminal justice system whereas psychotherapy actively seeks to minimise and alleviate trauma-based responses to internal and external stimuli.

Nonetheless, psychotherapists are encouraged to respect the fact that language has an impact and a meaning specific to the individual client. Therefore, the word ‘victim’ is not outlawed within psychotherapeutic dialogue especially if this is the term used by a client to refer to themselves.

Also used within this book is the word ‘we,’ which at times points to the fact that everyone has some contact with the challenges to everyday living raised by varying types of sexual violence. This includes psychotherapists who have lived experience, whether they are transparent about this in their working life or not.

Within psychotherapeutic work this could translate to ‘When we are going through something traumatic like sexual violence, it is normal for us to respond in the following ways …’ Being explicit that humans have neurophysiological mechanisms to automatically react to traumatic experiences normalises how we all try to survive them, rather than pathologising individual responses.

Beyond this, ‘we’ also solidifies the intention of undertaking work to collectively address sexual violence. Psychotherapists do so via appointments as well as having an active presence and participation in other spaces we each occupy personally and professionally. Examples can include informal support outside of traditional services or political activity.

Furthermore, each of the words qualified are deliberately applicable to any person of any gender, including those who identify outside of the categories of cisgender male or female. In this way we respect the truth that there are many types of people who have sexual violence in their history. Psychotherapists can take this as a helpful starting point to theoretically widen their lens on this topic, as well as practically invite a more diverse client base into their services from a place of integrity.

The use of commonly understood psychological terms such as ‘presenting concerns’ and ‘presenting material’ need to be explained at this stage. Such terms within this book refer to the client’s process of making their subjective experience and multi-faceted self known to their psychotherapist via implicit or explicit means. Clients can communicate these in conscious and unconscious ways.

This process includes the things the client wants to change via psychotherapy, their personal history, and how they relate to their own self or other selves. ‘Presenting’ in psychotherapy does not necessitate the client simply giving something to their psychotherapist which then only becomes the responsibility of the latter to hold. However, this can be a part of the work at times when disconnection (as the opposite of relatedness) takes place in some way.

The use of the word ‘clinical’ within this book is used to illustrate the issue of sexual violence as it appears in formalised mental health spaces. However, the use of this terminology does not assume that its appearance, along with the survivors that experience it, only takes place in these kinds of spaces. It is used to encourage the process of applying theory to practice in the reader.

Undertaking psychotherapy with survivors includes being entrusted with the truth of sexual violence. Part of the role of psychotherapists therefore is to step up to what is being shared via an active relational process knowing that the impact of such truths affects the client’s experience of their self, relationships with other selves, and contact with the wider world. An overview of challenges that clients often face is examined along the way so that psychotherapists can accommodate a working understanding of these, as they often present as challenges to advancing the shared work.

From wider world issue to individual struggle

Sexual violence is any act from one or multiple people to single or multiple others consisting of intended and/or actual sexual contact without seeking, considering, nor respecting consent. With this broad definition we can consider all the different types of sexual violence people can be subjected to, the diversity of individual survivors, the varying circumstances in which sexual violence occurs, and the many different kinds of people that can be perpetrators. On the ground, psychotherapists can expect to meet survivors who are as varied as the concerns they raise within appointments.

Sexual violence does not occur in a vacuum. It can often be mistakenly viewed as an isolated, random incident in an individual person’s life that is easily recovered from. The reality is that its impact becomes concurrent with and interwoven into the life of the survivor. For those who experience sexual violence in the context of pre-existing relationships, or during the process of human trafficking, this may ring especially true. The impact of this global issue on an individual, their relationships, and everyday life is tangible for extensive periods of time.

The global occurrence of sexual violence is so high that its commonality risks it being deemed as normal, but sexual violence is unequivocally not normal. It is not a developmental stage, incident, or life experience that validates a human being. It does not propel people forward in life from a solid internal or external base, particularly as the impact of sexual violence is not easily integrated anywhere at any level. What sexual violence does instead is repeatedly interrupt and disrupt one’s sense of self, as well as one’s relationships, and life.

A survivor’s truth no longer correlates with the various spaces in their life, which leads to adaptative and avoidant behaviours in order to retain some sense of safety. Again, this does not make the survivor abnormal. There is simply no other option within bodies, minds, relationships, and a wider world that are largely unchanging. Adaptive behaviours include navigating the level of actual or perceived threat of repeated unwanted contact from others and can be felt long after the last time threat was sensed.

Whether a survivor’s truth is believed, or not, strongly determines the practical process of accessibility to recovery after any disclosure is made. At a personal level, not being believed can be as traumatic or more traumatic than the sexual violence itself. For clients who have an ongoing close proximity to perpetrators, including living with them, this can mean remaining trapped in many ways for long periods of time. The wider world and relationships continue to be organised around the oppressive dynamics that ensure sexual violence goes on unaddressed.

Primal survival mechanisms are excessively activated that make individual bodies and minds feel out of control to the point of disempowerment. A consistently comfortable baseline cannot be found in any spaces within or beyond a client’s self and thus regular life becomes inaccessible as well as unbearable. Individual clients present with this to varying degrees from those who cannot participate in life at all, to those who are high functioning.

However it manifests, psychotherapists are invited into a survivor’s struggle and process of recovery, at the time they meet. Psychotherapists are offered an insight into a client’s life at that point as well as making contact with their past. This of course includes the incidences of sexual violence they have gone through. Once they meet, it is standard to focus on specific elements of the client’s presenting concerns in line with what they would like to be different.

Ethically, this is acting in accordance with a client’s needs or wishes. The work may be limited to only their initial requests, even as breadth or depth of conversations increase over time. This may be due to the practicalities of what is on offer from the psychotherapist, which in many services may be time-limited and/or non-specialist talking therapy. Psychotherapists may also meet a survivor unexpectedly, for example when a disclosure is made after a referral or assessment is completed.

With any client in any setting there are agreements to be made on how to proceed with the work on offer to maximise the efficacy of psychotherapy as a joint endeavour. There is always a careful balance to be found between focusing on what is emerging for the client, including in an urgent way whilst bearing in mind their overall presentation, history, and relational or attachment style. Interventions can then be tailored according to each client and takes into account their specific needs rather than providing a standardised service.

Barriers within the mental health system

For survivors of sexual violence what is essential to include in shared consciousness with their psychotherapist is their own experiences of disclosure and what accessing suitable talking therapy has been like. Such experiences necessitate psychological or physical contact with others and any contact is less safe following sexual violence, even if the survivor intentionally seeks it out.

It is impossible to work in a relational manner if psychotherapists only focus on symptom alleviation, as this overlooks the humanity of the client. To do so results in the person remaining lost amongst their trauma. A sole focus on symptom alleviation also does not fully prepare the survivor to re-enter the wider world as a multi-faceted self, along with their personal identity. In addition, a person’s humanity is violated at the time sexual violence takes place, which emphasises the need for psychotherapists to respond humanely thereafter as a restorative approach to facilitate meeting the person amongst the trauma.

Psychotherapy cannot be considered as a truly separate space from the rest of the world, as its privacy and confidentiality might appear to offer. The mental health system is a human-made system, which unfortunately means that the disempowering dynamics people can perpetuate against each other play out in this arena. Specifically, psychotherapy is not exempt from potentially disempowering those who wish to access it because of the many barriers that clients come up against in receiving help...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• 1. Sexual violence in context
• 2. The personal impact of sexual violence
• 3. Psychotherapy as activism
• 4. The challenge of myths
• 5. Working relationally with sexual violence in psychotherapy
• 6. Promoting empowerment in psychotherapy
• 7. Delivering pre-trial therapy in the United Kingdom
• 8. Vicarious trauma: Impact and management
• Index