The importance of a trauma-informed approach
This article reflects my decades of experience working with adult survivors of child sexual abuse (CSA). I began working with female survivors in the mid-1980s and with males in 1990. At that time, it was barely recognised that males could be victims of CSA. I have subsequently worked with hundreds of survivors including co-facilitating more than 50 groups for male survivors. The work has been both confronting and extraordinarily rewarding. I acknowledge the courage and wisdom of the survivors I have met and respect the trust they have placed in me.
The trauma-informed approach is a significant paradigm shift in the treatment of mental health issues. It leads us to ask what has happened to the person rather than what is wrong with them (Mayer & Agnew, 2019). In doing this, we acknowledge the significance of childhood trauma, the impact that has on the child and accept that childhood trauma can continue to affect a person into adulthood. Childhood trauma includes emotional abuse (neglect being the most serious form of emotional abuse) as well as physical and sexual abuse. Of course, many victims experience a combination of traumas which increase impacts on their normal development (van der Kolk, 2005). The trauma-informed approach also recognises the ubiquitous nature of childhood trauma which is behind many presentations to health and welfare services (Blue Knot Foundation, 2012).
Origins of the approach
Increasing recognition of the impact of childhood trauma has been developing for many years. Two pioneers deserve particular acknowledgement. The work John Bowlby began in the 1960s described the effects of disrupted attachment in young children and the importance of secure attachment for later development. His work laid the foundation for later recognition of child abuse causing injury through disrupted attachment. Judith Herman (1992) distinguished post-traumatic stress from what she coined ‘complex trauma’ which occurs over time and, most importantly, happens in the context of a relationship. The potential for trauma increases with the closeness of the relationship in which the trauma occurred. The trauma-informed model enables the origins of psychological injury to be acknowledged. It also introduces the possibility for survivors of CSA to rehabilitate from that injury with a realistic hope for a degree of recovery. It is the psychologist’s role to facilitate that recovery.
How is recovery possible?
There is one basic ‘rule’ when working with CSA survivors – safety. As psychologists we cannot assume that we understand what safety means for the survivor. We must explore it with them and openly explain that we aim to be a safe person and provide a safe space. Often, a CSA survivor has not spoken with anyone about what happened to them. The Royal Commission into Institutional Responses to Child Sexual Abuse (Final Report, 2017) found that the mean time between abuse occurring and the person disclosing (to anyone) was just over thirty years. Many have kept a secret for a long time, so it is important to acknowledge their courage in speaking about what happened to them. Providing safety is therefore crucial to help the recovery process.
Due to social norms surrounding privacy and even secrecy when it comes to sex and sexuality, members of the public and survivors are often quite uninformed about CSA and the effects of abuse that is sexual in nature. As a result an important role for psychologists is in psychoeducation of survivors.
Normalising survivors’ responses
As the range of sexual abuse varies enormously, so do the later effects on adults. However for all survivors it is reassuring to have their response to abuse ‘normalised’. Reminding survivors that, although it is not ‘normal’ to be sexually abused, their responses to being sexually abused are both normal and predictable. Many respond to this information by asking, “So you don’t think I’m mad (or bad or the only one)?” It also reassures them to hear information on the numbers of people who are sexually abused during childhood and remind them that it could happen to anyone. The abuse was not about them but about their vulnerability.
Memory
For many adult survivors, the abuse still seems immediate – as if it is in the present. It is crucial to clarify that the abuse is over and that the difficulties they are experiencing are because of the way in which the abuse is remembered in their brain. This should be done respectfully so as not to imply that their psychological pain is being minimised or not acknowledged.
As CSA survivors often find memories of abuse fearful, many will avoid thinking about it. An Australian Catholic bishop, himself a survivor, once described this perfectly when he said, “The memories were always there, but it was like they were in the attic of my brain – I never went there.” In this manner, many survivors avoid engaging with their painful memories and as such, the memories remain preserved as they were encoded at the time of the abuse, reflecting the child’s stage of cognitive and emotional development. Triggered abuse memories can activate emotions and physical feelings so strong that the survivor can feel that the abuse is happening again, encouraging further avoidance.
Children who were abused before they reached adolescence will often remain confused and frightened because at the time their body was not sexually matured, but nor was their brain. They did not understand what was happening. The Royal Commission found that more than 60% of witnesses claimed to have been abused between the ages of 10 and 18. That is, just prior to and during adolescence when young people are sexually maturing and beginning to discover their adult identity. It is a vulnerable period of development with a significant potential for harm.
From my experience, survivors abused before adolescence can experience both fear and confusion when the abuse happens and possibly a subsequent re-traumatising at adolescence when they realise the abuse was sexual. Psychologists can help with the recovery process by finding out the age at which the person was abused to better understand how they perceived it both at the time and now.
Providing a safe place enables the survivor to recall difficult childhood memories and update them as belonging in the past. As a result of recent work on neuroplasticity, we now understand that changes do occur in the brain. The way in which CSA survivors can radically change the way in which they experience abuse memories is a clear example of neuroplasticity in action (Siegel, 2010). Some of Siegel’s work, available online, is accessible to the public and an excellent psychoeducation resource for survivors.
Recognising that while the memories still impact them today, the CSA is in the past and part of their history, introduces the possibility for survivors to be safe in the ‘here and now’, and accept that the abuse happened ‘there and then’.
Different issues for female and male survivors
There are gender differences in the way CSA impacts adults. Both males and females can struggle with feelings of shame, fears of abandonment, sexual dysfunction and difficulties with emotional self-regulation. Additionally, a female survivor will often describe having been the victim of ‘slut shaming’, incorporating that into her self-concept. For many females abuse reinforces that relationships with males are often unsafe. Some women report being triggered when giving birth or breastfeeding.
Many male survivors frequently demonstrate confusion around their sexual orientation, especially if the perpetrator was a male and confused the victim by describing their relationship as ‘gay sex’ as opposed to the abuse of a child. Because it is not part of male stereotypes to be a victim, many male survivors will also have feelings of inadequacy around their masculinity. As one survivor said, “What sort of a man lets that happen to him?” The answer, of course, is a boy.
One of the greatest barriers to males seeking help is the fear that they will be seen as a perpetrator or potential perpetrator. Because perpetrators are mostly males, there is the mistaken perception within the community that if you are a male who was sexually abused as a child, it is only a matter of time before you start to abuse children yourself (Royal Commission, 2017). This belief is reflected by male survivors who often tearfully acknowledge their fear of being unsafe around children. Most male survivors do not go on to abuse children, however, it is true that a significant number of perpetrators are survivors of childhood trauma, including sexual abuse.
Shame and abandonment – the toxic pair
It is often confronting when a survivor describes themselves as dirty, horrible, evil, a bad person, a slut, or by other extremely critical terms. Guilt is feeling bad about something you have done, but shame is feeling bad about yourself as a human being. Unfortunately many survivors carry enormous burdens of shame. They perceive themselves as a bad person rather than a good person that something bad happened to (Fisher, 2013).
Shame must be addressed in recovery. Feelings of shame are often not conscious but are emotional memories relating to the abuse. When asked specifically about the origins of their shame, survivors can begin to recognise that feelings of shame are not based on fact but are emotional memories attached to abuse. Significant steps in recovery occur when survivors acknowledge that abuse was not their fault, that they have been brave to survive, and in fact have done the best they could.
Abandonment can be life-threatening for a child. A primary carer abusing a child is the ultimate act of abandonment, but many victims felt abandoned by other non-offending adults who did not protect them. Additionally some victims perceive that they were abandoned when other adults did not intervene because in fact, they were unaware that the abuse was occurring. The fear of potentially life-threatening abandonment follows some survivors into adulthood. The inability to feel competent to keep themselves safe results in ongoing attempts to get others to care for and rescue them.
The important conversation to be had with survivors continuing to fear abandonment involves acknowledging that unlike children, adults are responsible for themselves. Others can disappoint you or leave you but this is not life-threatening abandonment.
The only person who can truly abandon an adult is themselves. Helping survivors develop a contract not to self-abandon can assist in addressing this fear.
A new view of coping strategies
CSA survivors often experience difficulties with affect regulation. Their attempts to deal with levels of hyper- or hypo-arousal is often behind presentation to services. Intrusive memories of abuse that cause ongoing emotional pain and fear are distressing. Survivors attempt to ameliorate these feelings with behaviours that often become dysfunctional. Self-medicating emotional pain can become the numbing of substance abuse and addiction.
Alternatively, numbing extreme emotions can occur through distracting behaviours such as gambling, extreme risk-taking, addictive anonymous sexual activities and in recent times, compulsive use of electronic devices. Some survivors who used dissociation (the extreme of freeze response) to escape terrifying situations as children, continue to use dissociation to avoid stressful situations as adults. Briere (1992) acknowledges this by describing dissociation as an adaptation rather than a disorder.
It is important to view these behaviours as attempts to cope. The function of the behaviour needs to be explored to help the survivor develop safer strategies to self-regulate through less harmful coping skills. It is crucial to include strategies to deal with triggers, those events that remind the survivor of a fearful memory. This should focus on methods of self-calming after the trigger has gone off, rather than trying to avoid triggers, which are often impossible to anticipate.
Understanding grooming
An important aspect of psychoeducation is to explain grooming – the behaviours perpetrators often use to increase the vulnerability of a child to abuse or to keep the abuse a secret. Grooming can involve either threats or bribes.
When a survivor truly understands grooming it becomes very difficult for them to blame themselves for being abused. It is an excellent example of neuroplasticity, when their adult brain can comprehend something their childhood brain could not. During some of the men’s groups I run, it is common for participants to describe the session on grooming as the most useful.
Grief and loss
Sometimes we forget to address the grief and loss survivors experience following CSA. They describe losing their childhood or their safety, of losing a relationship with (non-offending) carers or missing out on education. For some survivors, it is necessary to explore a particularly difficult issue around their ambivalence regarding the loss of the relationship with the perpetrator. The acknowledgement of grief around such losses facilitates recovery and should not be overlooked.
The importance of groups
Having facilitated many groups for male survivors, I can attest to the enormous gains CSA survivors can make in a safe space with other CSA survivors. It does not replace individual therapy but is a huge adjunct to it. Being with other survivors overturns the dynamics of the original abuse. It challenges the secrecy, the isolation and seeing oneself as ‘bad’ or ‘different’. Provision of information written in easy-to-understand language (as many CSA survivors missed aspects of their education) encourages discussions and provides necessary psychoeducation.
The changes in the members of a group in just eight weeks is truly amazing and the work is very rewarding. Unfortunately there are hardly any CSA groups functioning at present either for men or women. This is a significant gap in services and one psychologists are capable of filling.
Self-care for psychologists
Finally I should mention the importance of recognising and managing vicarious trauma (VT) in the profession. Via our empathic engagement with CSA survivors, it is inevitable that we are exposed to and are affected by their trauma (Pearlman & Saakvitne, 1995). As psychologists we must view this as an occupational health and safety issue. VT needs to be openly and regularly discussed in supervision, signs recognised and ways to help manage it explored.
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The content of this publication is for informational purposes only and is not intended to be a substitute for professional psychological, psychiatric or medical advice. Support services in your state or territory can be found here. The APS Position Statement on Child Sexual Abuse and Psychology can be found here.