Walks and Thoughts

of Michael Simes

An old Man's Tale:

Shelf

Brighouse

West Vale

Clay House

Ripponden

Cragg Vale

Todmorden

Heptonstall

Pecket Well

Luddenden Dean

Jerusalem Farm

Catherine Slack

Stone Chair

It's Just Like Home:

Hong Kong

Auckland

Rotarua

Napier

Picton

Marlborough Sounds

Kaikoura

Milford Sound

Sydney

Manly

Blue Mountains

Northern Beaches

Thailand

A City Of Revolution:

Paris

Versailles

Sacré-Cœur

Notre Dame

The Adult Legacy Of Childhood Sexual Abuse


Individual Therapy With Adult Mental Health

Referrals Where CSA Is The Key Factor

Dick Agass And Mike Simes


This article, which arises from the shared experience of a psychiatric social work team, examines what is currently known about the long-term effects of childhood sexual abuse. It considers the challenges and pitfalls of individual work with adult survivors, presenting two detailed case studies as a basis for discussion. Key therapeutic issues are debated and constructive advice is offered for those social workers who find themselves increasingly involved in this complex area of work.

INTRODUCTION
Amidst the current upsurge of interest in the sexual abuse of children, attention is steadily focusing on the longer-term effects of abuse manifested by the rowing number of adult survivors now presenting themselves to professional helpers. Some experts declare that what we are now seeing is only the tip of the iceberg, and that there is a silent majority of predominantly female adult victims who have never disclosed their abuse. For most of these women secrecy was the 'organising principle' of their family relationships (Schatzow and Herman, 1989), and they have carried their burden into adult life disguised beneath a mass of secondary difficulties and disorders (Gelinas, 1983). Almost a century after Freud's much-analysed retreat from the 'seduction theory' as an explanation of adult hysterical neurosis (Masson, 1984), we are still a long way from accepting the unpalatable truth about sexual abuse, which is so disturbing that it constitutes a sort of societal 'blind spot' (Summit, 1988). If, as Vizard (1988) claims, it is only when the external world acknowledges abuse that the internal world of the victim can do the same, then perhaps we are at last beginning to break our collusive silence and to counteract some of the divisive and stupefying effects that sexual abuse can have on victims, on professionals and on the public at large (Sinason, 1988; Kraemer, 1988). If this trend continues we can expect more and more adults to seek help specifically for the effects of past abuse, rather than not seeking help at all, or seeking help for something else, either because they cannot talk about the abuse or because they have repressed it (Faria and Belohlavek, 1984).

In the meantime more and more helping professionals are being confronted by disclosures of sexual abuse, often in the course of therapeutic work undertaken for something else. Many victims present mental health problems, most commonly some sort of depression (Gelinas, 1981; 1983; Bifulco et al, 1991), or a whole cluster of other symptoms which, in the USA, carry such psychiatric labels as 'borderline personality disorder' (Steele, 1986; Sheldon, 1988) and 'post-traumatic stress disorder' (Lindberg and Distad, 1985; Patten et al, 1989). Some clinicians identify a distinct 'post sexual abuse trauma' (Briere and Runtz, 1988). Symptoms vary from the predominantly mental to the predominantly physical, but often there is an intermingling of psycho-somatic disturbances. Sinason (1986) reports cases of abused children whose cognitive development has been drastically impaired. It is possible that some victims develop chronic psychosis as a result of their childhood experience (Beck and van der Kolk, 1987). On the other hand, many abused children present only physical complaints, indicating that even if the mind manages to forget the abuse the body may continue to remember it (Vizard, 1988). In the longer term, relationship difficulties involving sexual dysfunctions are commonly reported (Jehu, 1988; 1989), and eating disorders in adult women are strongly associated with adverse sexual experience in childhood (Pa1mer et al, 1990). A high proportion of adult women who 'somatise' their psychological distress are likely to have been molested as children (Morrison, 1989). Indeed, some abused women develop such severe physical symptoms that they are treated surgically, even though no organic basis for their problem can be found (Amold et al, 1990).

However they manifest themselves, the lasting effects of sexual abuse are currently being subjected to more and more detailed investigation on both sides of the Atlantic (Jehu, 1988; Wyatt and Powell, 1988; Hall and Lloyd, 1989), and reviews of the available research are beginning to appear in professional journals (e.g. Cahill et aI, 1991; Sheldrick, 1991). A social work literature on the subject is also beginning to emerge, with a notable home contribution from the University of East Anglia (Kenney, 1989; Osborn, 1990). The present article is intended as a small addition to this growing area of therapeutic work. As mental health social workers we have found ourselves involved in a number of cases where previously undisclosed CSAhas emerged as a determining factor in the subject's life experience and current personal difficulties. We are aware that many of our colleagues are encountering the same phenomenon - indeed, this article could not have been written without the support and shared experience of a hospital social work team. We shall describe two such cases of our own in some detail, deliberately concentrating on the element of sexual abuse - how it emerged in each case, what part it played in the person's life, how all this was handled in the work and with what results. We shall then compare our own experience with the findings of others, as gleaned from recent clinical and research literature. Finally we consider some (though by no means all) of the key issues involved for social workers in working with adult survivors of abuse.

It will be clear that our own approach is psychodynamic, with particular emphasis on transference/counter transference processes. This is not the only way of working: practitioners need to develop the theoretical base and practical skills best suited to themselves and their clients. Our experience is also limited to individual work, though we acknowledge the widespread and effective use of groupwork in this field. As far as terminology is concerned, we have mostly used the terms 'work'/'worker' rather than 'therapist'/ttherapy' because we are writing for social workers in general and not for a select group. Social workers are not psychotherapists, but therapeutic work is a valid and vital extension of social work practice. In our experience many social workers are personally and professionally equipped to take on this kind of work provided they have access to regular and well-informed supervision and can make full use of whatever further training they can find.

One final introductory point. Throughout this paper we prefer the term 'sexual abuse' even when discussing intra-familial abuse which might more appropriately be called 'incest'. To talk of , abuse' reminds us of the central issue here - namely the mis-use or exploitation of a child for sexual gratification by an older (and often closely related) person who occupies a position of trust or authority in relation to that child. Basic to the child's experience is that she is incapable of giving informed consent or of exerting any control over what is done to her. Our choice of personal pronouns in general discussion reflects the fact that most victims are girls and most abusers men.