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You may open and print this article as a one-pager for handouts or use in a newsletter: Sexual
Abuse Counselling by Family Physicians
Sexual
abuse reportedly affects one in four women and one in ten men.1 The
Canadian Incidence Study of Reported Child Abuse and Neglect (final report 2001)
found that sexual abuse accounted for 10% of all child
maltreatment investigations in 1998 with 38% of those found to be substantiated.2
Further: Touching
and fondling genitals was the most common form of substantiated child sexual
abuse, occurring in 68% of cases. Attempted and completed sexual activity
accounted for over one-third (35%) of all substantiated reports. Adults exposing
their genitals to children was reported in 12% of cases…2 Sexual
abuse is now linked to a number of personality, conduct, affective, eating, and
substance abuse disorders.3, 4, 5, 6 However, sexual abuse as
underlying the aetiology of these various disorders and complaints continues to
go unnoticed and untreated in many cases. Freudian
psychology and analysis brought forth possibly the greatest proliferation of
thinking on the determinants of the human psyche and by extension, human
behaviour. At the same time it obscured for almost three quarters of a
century the fact that many women's hysteria or neuroses was founded in the
reality of childhood sexual abuse as opposed to fantasy. Freud
had acknowledged real trauma, of course, but he put his emphasis on the
child’s intrapsychic world of sexual desire and fantasized sexual experience,
he did not develop a description of how real traumas can effect a child’s
development. In the late 1920’s and early 1930’s, Freud’s colleague and
friend in Budapest, Sandor Ferenczi, did develop very vivid and compelling
portraits of the consequences of childhood sexual seduction and abuse, and
formulated a rich theory of sexual traumatization, but this work was
marginalized in psychoanalysis and almost unknown in non-psychoanalytic
psychology and psychiatry until the emphasis in CAN (child abuse and neglect)
on sexual abuse brought it back into consideration.7 We
are still coming to terms with the greatest obfuscation to a childhood reality
that may have ever occurred. Only
now are people regularly daring to ask the questions that make way for clear and
detailed accounts of sexual abuse, yet many family physicians still do not
screen for childhood trauma even though advocated in the literture.8
For the family physician, instruction on evaluating childhood sexual abuse is as
recent as the 1990’s.9, 10, 11 Further: Physicians
are in a unique position to assist victims of sexual abuse during the healing
process. Awareness of childhood sexual abuse and how to intervene when childhood
sexual abuse is suspected, however, are not part of most physicians' basic
training. Developing these skills may be one of the most valuable ways for a
family physician to expand and improve the care he or she provides.6 More
family physicians are venturing into the world of talk therapy and are able to
utilize their unique knowledge of psychopharmacological intervention to assist
the process of recovery. On the matter of counselling per se, a simple structure
for detailing the counselling process may be of value. To
this end, this article provides such a structure as a simple heuristic to
support those family physicians that endeavour to directly counsel adult
survivors of childhood sexual abuse and help other physicians identify when to
refer for specialized counselling. Sexual Abuse Counselling has a Beginning, Middle and an End Counselling
with sexual abuse survivors can be conceptualized in three stages. Each stage
has a series of core issues most of which are common in many counselling
processes, but are particularly relevant for sexual abuse counselling. The
following chart summarizes each stage and the core issues to be addressed. Each
stage will be expanded upon in subsequent sections.
The Beginning Stage Patients
see a physician owing to some form of distress. If there weren’t distress,
there would be no need for help. The distress may be expressed as physical,
psychological, emotional, behavioural or psychiatric symptoms. The call for help
occurs when symptoms exceed a tolerable threshold. To the patient yet to link
their distress to issues arising from childhood sexual abuse, it may be the
inquiry of the physician that provides the initial link and raises the issue of
childhood sexual abuse. For other patients, they may be aware of their past
abuse and are seeking help to address consequent distress. Either way, the
beginning stage of counselling begins with disclosure of a past childhood trauma
by the patient to the physician. This first stage of counselling may therefore
characterized by issues of trust, self-doubt, shame by the patient and fear of
recrimination by the physician towards the patient if the patient views him or
her as tainted given the abuse experience. Advance
preparation by the physician is necessary in order to manage the disclosure
appropriately such that trust is developed with the patient. The trust is in the
order of the patient being believed and not being judged negatively or as
contributory to the abuse disclosed. Such physician preparation takes the form
of prior reading on the topic and a basic understanding of the dynamics of
sexual abuse, power imbalance and impact on child and adult functioning. The
sense of trust as felt by the patient is crucial to their sense of safety and
security with the physician. The issue of safety and security for the adult
survivor is more psychological and emotional than physical per se as the abuser
is likely no longer in proximity to the survivor. However, this statement should
not be taken as a fact, but as a hypothesis to be explored as a good many
survivors do carry on relationships with their abuser, particularly when the
survivor is yet to acknowledge the abuse or confront the abuser (should they
choose to do so). It may be necessary right then and there for the physician to
counsel the patient on issues of safety, if only psychological safety, in the
event a relationship with the abuser continues. In
addition to advance preparation through reading and the like, the physician is
advised to explore their own feelings and issues on the matter of childhood
sexual abuse. This is to acquaint and acclimatize them with feelings that may
arise in themselves when confronted by matters of childhood sexual abuse. In
much the same way physicians may have to acclimatize to the surgical theatre
during medical training, they may find a similar acclimatization process of
value so as not to overwhelmed by the intensity of their own feelings as well as
their patient’s feelings which can be delivered with significant emotional
intensity. As
a result of the disclosure, the patent may experience a flood of various
emotions, which in turn may trigger a variety of defence mechanisms, up to, and
including dissociative states. Further, the patient may experience vivid
recollections of past abusive events. These recollections may inundate their
consciousness during waking hours or intrude during sleep as nightmares. These
are the hallmarks of Post Traumatic Stress Disorder (PTSD). The interventions of
the physician include empathic listening, and reassurance to the patient that
they are in a safe place whilst with the physician and that they are believed in
their disclosure. Important in the first or initial stages of disclosure is
actually limiting the disclosure so patients avoid overwhelming themselves. In
future sessions as the patient comes to review their abuse history and
acclimatize to the acknowledgement of their abuse, greater disclosure can
proceed. By this time, the patient will have experienced the psychological
safety the physician provides and can be more comfortable with greater
disclosure sans the risk of being overwhelmed. The
beginning stage concludes with the physician educating the patient as to the
counselling (treatment) process, the psychological and emotional sequelae of
addressing one’s sexual abuse history and the supportive use of
psychopharmacological interventions if necessary to alleviate anxiety or
depression.
The
Middle Stage The
middle stage of counselling begins as a continuation of the first. Issues of
trust, safety and security are emergent and reoccurring themes. If there has
been a prior unsuccessful counselling effort the patient may be ambivalent about
the physician with concerns that the shortcomings of the previous experience
will be experienced yet again. It is therefore important to survey prior
counselling experiences with a view to determining present attitudes and
concerns as matters for displacement upon the physician that can interfere with
the counselling relationship. Given
different types of abuse, intra-familial and extra-familial, it is also
important to identify the relationship of the abuser to the survivor and the
context of the abuse as this will have additional bearing on trust, safety and
security issues. With intra-familial sexual abuse the survivor often experiences
issues of trust with intimate partners. With extra-familial sexual abuse, the
survivor may have difficulty trusting either strangers or other persons in
positions of authority. Some patients will have experienced both forms of abuse
and hence their ability to trust under any circumstance may be fragile. In these
cases, the development of trust with the treating physician may take longer to
establish. As
the middle stage of counselling begins the patient’s sense of trust, safety
and security can be facilitated by several interventions. At this time a limited
course of anti-depressant medication, anxiolytics
or sleep medication can bring symptomatic relief. (Even though patients are told
that anti-depressant medication may take several weeks to reach therapeutic
level, many are significantly comforted by the prescription alone.) Availability
for crisis counselling, after hours availability and even permission to phone in
the middle of the night can provide enough comfort to actually mitigate the use
of the very service offered. This author routinely permits patients to phone 24
hours a day and informs the patient that a call for a five-minute conversation
to reassure is preferred over their increasing distress which may result in
breakdown and hospitalization with resultant additional issues to address and
overcome. Given the reassurance such availability provides, patients rarely call
and are reluctant to misuse this privilege. If a patient should call, there is
likely good reason and significant distress. However, no patient of this author
has ever had to be hospitalized in the event of a call. Rather, with
reassurance, the patient either manages to await a morning crisis appointment or
the matter resolves itself and the patient is next seen at their scheduled
appointment. As
counselling progresses, the patient’s defences will relax and more personal
detail of the abusive events may be disclosed. While this is the time in
counselling that some patients may further identify and explore the
manifestations of abuse, the risk of the patient becoming overwhelmed remains.
The role of the physician is to normalize these reactions and help the patient
pace their disclosure and exploration of events and thus facilitate them gaining
control of their own emotions and reactions. Throughout, the physician helps the
patient make connections from past abusive events to present day symptoms In
the middle stage of counselling the patient may experience relief and/or
exacerbation of symptoms. This is to be expected as they come to address issues
of distress. The physician can draw a simple graph as shown below to illustrate
the likely ups and downs the patient may experience over the course of
counselling. By demonstrating and predicting these fluctuations they are then
normalized and no longer viewed as evidence of deterioration by the patient, but
rather are reframed as evidence that the patient is moving through the recovery
process.
In
helping the patient to gain control of their emotions and reactions and in
helping to make connections between past abusive events and current symptoms,
the patient gains understanding of their situation and problems therein. They
learn that the abuse and current symptoms are not a function of their worth,
value and humanity, but wrongful events perpetrated against them beyond their
control with devastating effects owing to the dynamics of the situation. Through
the counselling process the survivor learns to separate their sense of self from
the abuse and the abuser and learns to establish an independent identity through
which they may now make conscious choices. They are then in a position to learn
cognitive and/or behavioural strategies for managing symptoms and they can more
appropriately assess their own interpersonal relationships and make choices
therein. They are better able to identify and separate their needs and issues
from others, and where appropriate, place their needs ahead of others or
alternately as in the case of parenting, put their children’s needs ahead of
their own. Over
time and as the middle stage of counselling continues, symptom reduction is
expected. The course of the reduction can take several forms including
reductions of intensity, duration and frequency. It may be important to discuss
with the patient these various indicators of symptom reduction. Some patients
who experience intrusive and vivid recollections of past abusive events may
experience them with the same intensity, yet either their duration or frequency
may diminish. Alternately, intensity may diminish but duration and frequency may
remain the same. It is therefore
important to review symptoms along these three dimensions so as to provide
tangible evidence to the patient that symptoms are improving. In time symptom
reduction in all dimensions is expected and preferred, but the patient must be
informed that change may not occur in all manner equally, nor in a linear
progression. As
patients gain insight and develop their cognitive and behavioural repertoire to
mange themselves, the role of the physician changes from active intervener to
observer/witness and at times cheerleader. The physician now plays a powerful
role in reinforcing the changes through significant positive feedback based upon
tangible symptom reduction and improved psychosocial functioning. Nonetheless,
even improvement carries risks. As a result of counselling, some patients will
move from depression to anger at the perpetrator and may then require
information and support as they consider a range of responses. The responses can
include; discussion with other family members, friends or community members;
confrontation with the abuser; and even making a criminal report to police with
the intent of seeing criminal charges laid. Some patients, having explored their
family system and the role of the abuser, may move on to explore the role of
other family members whose silence may now cause them to be viewed as
co-conspirators or enablers through acts of commission or omission. Furthermore
and as a result of counselling, the patient’s current interpersonal
relationships can be destabilized. Couple or family counselling may be indicated
to facilitate systemic adjustments. These interventions can occur concurrent to
the patient’s individual counselling (parallel process) or after individual
counselling has been terminated (serial process).
The
middle stage draws to a close as the patient demonstrates enough symptom relief
and improved psychosocial functioning to manage independently. The issue as they
enter the end stage of counselling is fear of letting go of physician support,
relapse and reconnecting with established or new social systems. The End Stage As
with any successful counselling process, the patient tends to feel gratitude and
a reluctance to let go. However, in the case of sexual abuse counselling, these
feeling may be intensified. It is common for sexual abuse survivors to have had
very fractured separations from their family of origin, particularly in the case
of intra-familial sexual abuse. Their relationship to the physician-counsellor
may have been their healthiest inter-personal experience in that it was
non-exploitive. This can give rise to a significant attachment of the survivor
to the physician. It is important then for the physician to reaffirm their role
as helper and although caring, not an ongoing figure in the survivor’s life.
In much the same way as Dante had Beatrice and Dorothy had a tin man, cowardly
lion and scarecrow, the physician is but a passing helper in the life of the
patient. These and other similar stories may help the patient come to terms with
the end of counselling and the role of physician as counsellor. The
patient will naturally struggle, vacillating between confidence and doubt.
Historically their self-management has been tenuous; otherwise they would not
have sought outside relief from distress in the first place. It will take time
for them to learn to rely on their improved psychosocial functioning and new
skill sets. The patient may demonstrate a rapprochement with the physician
understanding the need to separate and terminate yet requiring a sense of
closeness and availability at the same time. All these matters are grist for
discussion and problem solving in the end stage of counselling. Interventions
include reviewing progress, providing reassurance and at times offering a
graduated termination process. A graduated termination process generally sets
out a series of successive appointments with greater duration between
appointments over time and for lesser duration per appointment. Some patients
can be reassured by knowing they may reconnect if they feel the need. For some
this is conceptualized as a “booster shot”. For
some patients the end of the physician counselling may be the beginning of other
services such as ongoing support groups or educational opportunities. In all
cases, the survivor is encouraged to go out into life, manage ambiguity and
uncertainty, learn and flourish.
Discussion The
counselling process described above is provided as a heuristic to enable family
physicians to better manage their treatment of adult survivors of childhood
sexual abuse. In the context of this author’s private counselling practice and
during an extensive history taking, all clients are routinely asked if
they have ever been touched in a way that has made them feel uncomfortable. The
question as posed, opens the door to every imaginable form of touching. If the
client truly has not had an unwanted touch of any type in any manner, they
quickly say no. However, if the client has had an unwanted touch, they may
disclose it quickly, or divert from eye contact so as to avoid the question, but
thus already giving indication of an issue that may bear further exploration.
Some answer the question with a question, seeking clarification, “do you mean
sexual, or physical.” Again however, the client thus provides clues of
unwanted touching experiences. At times though, even when asked, some clients
are so psychologically removed from the abusive events that it fully escapes
their awareness, only to surface later. The
case examples below come from this author’s private practice. Names and
identifying data have been altered to protect the identity of patients and other
people. Sexual
abuse counselling is a vital intervention as the issue is contributory to so
many forms of adult personal and interpersonal dysfunction. It is this
author’s hope, by way of this article, that those physicians who practice
counselling may be better equipped to help and those who do not practice
counselling will be better informed as to thus make appropriate referrals for
treatment. References
1.
Faller, Kathleen Coulborn,
Child Sexual Abuse: Intervention and Treatment Issues, User Manual
Series, U.S. Department of Health and Human Services, Administration on
Children, Youth and Families, National Center on Child Abuse and Neglect, 1993 2.
Trocmé, Nico, et al, Canadian
Incidence Study of Reported Child Abuse and Neglect: Final Report,
National Clearinghouse on Family
Violence, Health Canada, 2001 3.
Windle
M, Windle RC, Scheidt DM and Miller GB, Physical
and sexual abuse and associated mental disorders among alcoholic inpatients, American
Journal of Psychiatry, American Psychiatric
Association, 1995; 152:1322-1328
4.
Whealin, Julia, Child Sexual Abuse, A
National Center for PTSD Fact Sheet, at www.ncptsd.org/facts/specific/fs_child_sexual_abuse.html,
accessed October 27, 2004 5.
Polusny MA, Follette VM, Long-term correlates of child sexual
abuse: Theory and review of empirical literature. Applied and Preventive
Psychology 4:143–66. (1995). 6.
Hendricks-Matthews,
Marybeth,
Caring for victims of childhood sexual abuse – Editorial, Journal
of Family Practice,
Nov, 1992 7.
Young-Bruehl, Elisabeth, Discovering
Child Abuse,
Section V
of the Division of Psychoanalysis of the American Psychological
Association, at www.sectionfive.org/essay_young_breuhl2.htm,
accessed October 27, 2004 8.
Seng JS, Petersen BA, Incorporating
routine screening for history of childhood sexual abuse into well-woman and
maternity care, Journal
of Nurse Midwifery, 1995
Jan-Feb;40(1):26-30 9.
Bala M, Caring
for adult survivors of child sexual abuse. Issues for family physicians, Comment
in Canadian Family
Physician, 1994 Sep;40:1509 10.
Vincent,
E. Chris, Gibbons Mary, What
you need to know about childhood sexual abuse – Editorial, American
Family Physician,
Feb 1, 1995 11.
Guidry,
Harlan
Mark, Childhood
sexual abuse: Role of the family physician, American
Family Physician,
Feb 1, 1995 12.
Dybicz, Phillip,
An Inquiry Into Practice Wisdom, Families
in Society: The Journal of Contemporary Social Services,
Alliance for Children and Families, 2004, 197-203
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Gary
Direnfeld, MSW, RSW www.yoursocialworker.com Call Gary for your next conference and for expert opinion on family matters. Services include counselling, mediation, assessment, assessment critiques and workshops. Buy
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