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


ISSUES IN THE WORK
Therapy offers adult survivors a 'second chance' to do what they were unable to do at the time of the abuse - namely, to engage in the emotional work required to overcome the original trauma and alleviate its pain (Gardner, 1990). No therapeutic work is easy, but working with adult survivors of CSA presents special difficulties and raises some challenging issues. The final section of this paper considers three distinct but related themes:
  1. sexual feelings in the work;
  2. the issue of the worker's gender; and
  3. basic requirements if the work is to have a chance of success.

Most therapeutic encounters stir up strong feelings in both client and worker. Because sex is such a vital part of our make-up, any close relationship which has a nurturing function and which encourages a replay of the client's past will inevitably re-activate aspects of sexual development which have a strong bearing on current sexual activity. From Freud (1915) onwards there is much discussion in the therapeutic literature about the client's erotic transference' towards the worker, but relatively little about such feelings in the other direction, from worker to client. For many years 'countertransference' feelings were thought to hinder rather than help the therapeutic process, and there is still a general reluctance to discuss the erotic component of such feelings (May, 1986; Field, 1989). Since the worker's emotional (and physical) reactions are nowadays regarded as a vital source of information about the client's unconscious communication (e.g. Casement, 1985; 1990), the key question about any strong feelings (including sexual ones) aroused in the worker is: What is being communicated to me about the client's innermost experience? Workers need some way of analysing their own reactions so that they can distinguish between those which are predominantly personal and those which have a potential diagnostic value in helping them to understand the client (Casement, 1985, eh 4).

Working with adult survivors of abuse raises extra complications in this already difficult area. The most obvious is that the victim's sexual feelings have been stimulated and exploited before she has reached an appropriate level of emotional and psychological maturity, and before she could exercise any control over what was being done to her. Her sexual development has been hijacked and diverted from its natural course, so that sexual feelings have either become hopelessly confused with non-sexual feelings of affection, or else they have been contaminated by feelings of revulsion, fear and guilt. As a consequence she may over-sexualise all her relationships (since she has identified sex as the currency of affection), or else she may recoil from anything sexual. These are among the long-term effects that Finkelhor (1988) refers to as 'traumatic sexualisation', one of the crucial dynamics at work in the aftermath of abuse.

As far as the work is concerned this means that sex is bound to be an issue, whether it is powerfully present in some way (as with Christopher) or lurking somewhere in the background (as, mostly, with Helen). The worker may become the focus of the client's sexual feelings, and may himself become aroused. In such cases the worker may not be at all sure whether these are his own 'real' feelings or whether he is being manoeuvred into a role and responding to the client's projections - or even whether any such distinction makes sense. Sometimes sexual feelings can be stirred up by a client who is unconsciously disowning them and projecting them into the worker (Casement, 1990, ch 4). All this can leave the worker with the baffling impression that he is 'playing a role from a script he has never seen' (Field, 1989). Such feelings can be profoundly disturbing, even overwhelming, if the interpersonal dynamic at work in the therapy is not properly understood and turned to therapeutic effect.

The case of Christopher illustrates some of these processes. According to Dimock (1988), the biggest impact of sexual abuse on male victims is in the area of their sexuality, leading to 'masculine identity confusion' and a tendency to sexualise their relationships with other men. With Christopher the eruption of sexual feelings only occurred when a trusting relationship had been established (fusion of sex and nurturing/affection). For some time the worker had been struggling with the awareness that something sexual was going on, but was unsure whether he dared pick it up. Eventually it became impossible to avoid doing so, and for a while the strength of sexual feeling passing between them profoundly disturbed his equilibrium. It was only when he realised the informational value of what he was experiencing that he was able to use his own personal feelings in a diagnostic way to understand what Christopher had been through and to help him overcome its continuing effects. If the worker had not been able to do this he might well have repeated Christopher's history by either pulling out of the case and thus rejecting him (like his family), or responding in some sexual way and thus abusing him (like the brother).

This case also confirms Dimock's (1988) point that in order to sort out his identity confusion a male victim needs to be affirmed as a man by other men - something his father (for whatever reason) has normally failed to do. By responding in the way he did the worker clearly managed to validate Christopher's masculinity without denigrating his homosexual feelings. The case further illustrates the proposition that perhaps the most helpful thing the worker can do is to experience and 'contain' the powerful feelings generated in the work without being overwhelmed by them and without acting on them, thus enabling the client to stop repeating past themes and to repair some of the early developmental damage (May, 1986). This sexual healing may then carry over to other relationships.

The presence of sexual feelings should be taken as normal for this kind of work, regardless of gender. Female workers seem to experience the same sort of sexual pressure from female survivors. Common-sense would suggest, however, that the strongest sexual tension occurs when the original abusive gender configuration is reproduced (as in both our reported cases). Should this be encouraged or avoided? Gardner (1990) argues that male workers are handicapped by 'fantasies of penetration and conquest' in relation to female clients, and that a female worker can better empathise with the fear of male abuse. Presumably 'male' in this context means heterosexual male: would a homosexual man make a better therapist? Male sexuality contains a whole spectrum of proclivities and attitudes and it is surely unwarranted to suggest that heterosexual male fantasies are invariably about 'conquest' rather than, say, closeness. According to Kenney (1989, p.21), many feminists take the line that in the overwhelming majority of cases 'women are the only appropriate workers for sexually abused adults, as they do not represent an abuser (apart from a small minority of cases) and there is less likelihood of any sexual feelings being engendered in the survivor or the therapist'. This assumption, that sexual feelings can and should be kept out of the work altogether, seems to us simplistic - though we appreciate the fear behind it that a vulnerable female survivor could be open to further exploitation by a man in an unequal power relationship. We also acknowledge that in the vast majority of cases, despite the growing evidence that women are also perpetrators (Elliott, 1992; Wolfers, 1992), sexual abuse is fundamentally an abuse of male power reflecting the structural inequities of a patriarchal society (Ash, 1984; Dominelli, 1989). However, far from accepting that any of these factors should disqualify men from this work, we agree with Mann (1989) that the potential benefits for a female survivor of working with a male therapist are considerable. If it can be said that there is an intrinsic connection between child sexual abuse and traditional patterns of male sexuality, and that 'we (men) are all implicated in the processes by which sexual abuse takes place' (Frosh, 1987), then surely this is all the more reason for men who do not abuse to be involved in repairing the damage. We believe that a good male worker can provide something qualitatively different from an all-female therapeutic environment, which might be tempted to deal with the problem of maleness by shutting it out altogether. Of course this should always be, as far as possible, a matter of choice for the client. But if a male worker can understand and resist the powerful 'invitation to abuse' presented to him by a female survivor, and if he can provide her with an alternative model of a man who is nurturing and non-exploitative, though still sexual, then the survivor may be able to rewrite her internal script, rediscover her strength and self-direction as a woman, and exercise a more meaningful choice as to whether she avoids men altogether or else re-orientates herself towards men who will not simply perpetuate the original abuse.

In conclusion we offer a round-up of what, for us, are some of the key requirements for effective work in this challenging area.
  1. The experience of CSA is often partly or wholly repressed, and may only begin to emerge when work is already underway for something else. Workers should be alert for possible signs of past abuse, and should create the right environment for disclosure. This means being aware not only of the common presenting symptoms but also of the life-events that may act as 'developmental triggers' (Gelinas, 1983) to re-activate the original trauma - for example, if there is a daughter approaching the age at which the survivor herself was first abused. Ideally disclosure should be allowed to happen in its own time and in its own way, and should not be forced, though sometimes it is appropriate to pursue a line of enquiry quite persistently. Survivors may also need considerable help to find the words with which to describe their experience. Once the abuse is in the open it is important not to concentrate on it to the exclusion of other areas of deprivation and damage in the person's life. This can repeat the distorting effect of the original experience.
  2. Workers should be aware of the changing understanding a child will have of the abuse as she grows and develops. Osborn (1990) makes this point particularly well, using developmental models from Freud, Erickson and Piaget. For example, in the 0-5 age group when abuse commonly begins (Hobbs and Wynne, 1989), many children still see their parents as all-powerful. so that a girl being abused by her father may imagine that her mother must know all about it. This belief can have a major impact on the child's processing of the experience. The long-term effects of abuse can only be dealt with if the worker understands how a particular survivor experienced and is still experiencing her abuse. 'This experience cries out for validation in the face of so much confusion, ambivalence and self-doubt. The client's own account of her experience must therefore be taken seriously, with as much attention to the external events as to their internal impact (Sheldon, 1988).
  3. Clients may need to come and go in the therapy. A vital first step is for the worker to communicate the optimistic conviction that talking will help. Once this has been done, the client may need 'time out' after disclosure, with the door left open for her to return whenever she feels ready for the next stage. It is important to let this happen, provided the worker is quite clear that s/he is not colluding - i.e. not secretly wanting the client to go away because the problem is too hot to handle. 'Leaving' is something the victim could not do in the original situation, and it is important for her to discover this freedom whilst being able to remain in touch. Helen fled from the room in a number of sessions when the abuse was coming back to her and when she began to feel strongly towards the worker as 'father'. Usually she would make contact by telephone afterwards to talk over the experience, which made it easier for her to come back for the next session.
  4. Strong feelings will naturally be focused on the perpetrator (usually father, step-father or other male relative), but there will often be equally strong negative feelings towards the mother for her perceived failure to protect and support. Survivors may even retain affection for the abusing father whilst feeling contempt for the mother, and this latter feeling can sometimes dominate the person's life. This can raise difficulties, especially perhaps for a worker who sees such fathers as total villains, or who identifies strongly with the mother as a fellow-victim of oppression. Care should be taken not to invalidate the client's experience through adherence to one's own emotional or political agenda.
  5. Given that abusive themes are unavoidably re-enacted in the therapy, workers have to find some way of monitoring their involvement so that they do not simply get drawn into the continuing drama. The requirement is twofold. Firstly, workers must be able to cope with the powerful and disturbing impact this work has on their own feelings. They must be prepared to face intense pain and anger in their clients, and they must also be prepared to work on their own personal development and self- awareness. Abuse victims quickly tune in to how much the worker can tolerate, and in order to come to terms with their own experience they need to know that the worker can withstand it emotionally whilst continuing to function therapeutically. If the worker has 'terrors and unresolved struggles' (Sinason, 1988) about sexual abuse - and we need to bear in mind that some workers will themselves have been abused - then the outcome may be disastrous. The second requirement is that the worker must have access to regular, skilled supervision, preferably backed up with some sort of specialised training. If this is not available in the immediate work-setting, workers should seek it elsewhere (Hawkins and Shohet, 1989, ch 3), if necessary pressing their agency or department to pay for it. One possibility would be for team members to set up their own special interest group in order to support and supervise each other in what can be lonely and disturbing work. Departments and agencies might also pool their resources so that, for example, a hospital team which has acquired experience in working with adults could consult and eo-work with an area team whose primary expertise is with children. Good supervision is all the more vital for workers who unsuspectingly take on a case only to find themselves dealing with abuse as the tale unfolds (an increasingly common occurrence). They may feel overfaced by the problem whilst being reluctant to break the relationship, particularly since the client has trusted them enough to disclose. To press on in such circumstances without skilled help might be asking for trouble.