Ways To Address Sexual Abuse Survivors: A Therapist's Essay.

Identify the client’s presenting issues and any other factors that would need to be taken into account when working with this client. Discuss possible ways of working to address these issues, drawing on your knowledge of integrative practice, and particularly on your knowledge of appropriate theory and skills. Incorporate reference to relevant literature to substantiate your discussion and analysis.

To do this assignment you need to choose a client described in the vignettes (scenarios) . When you have decided which client (scenario) to choose you use the information about that person to discuss how you would work with them based on what you have  readings (please see some of references list i provided, you can add more ) this is just some of recommended reading for this course but it needs more references for the assignment to be completed

Discussion

Sexual abuse is any kind of sexual violence, which can be rape, childhood molestation, incest or any other similar form of forced sexual contact. However, sexual abuse is not only about sex rather it is a venture to try to gain control over the victims. Life of the sexually abused can be saved if they are given immediate assistance. Along with it therapies also helps those victims overcome their trauma of sexual assault in the past. There are also some victims who may need long term support which in a way beneficial to those survivors. However, sexual abuse of children can take many forms and may involve behaviors where there may be no physical contact like revelation or voyeurism. The most common cases are of children who are sexually abused before the age of 18years. This type of act mainly occurs due to sexual attraction towards children and because the offender tries to gain control over the victim who is a child. Maximum of the time it is found that the child is either threatened or manipulated by the offended to prevent themselves being disclosed (Mrazek & Kempe, 2014).

The government is also changing their laws related to sexual abuse constantly and so the feelings of the survivors of the sexual abuse are given more importance than the laws. However, about 93 percent of the children who are sexually abused remember their attackers and one third of them are from the victim’s family. Thus, the programs through which children learn that they have to be careful in front of strangers cannot really help avert all kind of abuses. In maximum of the cases, it has been found that the child victims do not tell anyone about the trauma they are experiencing or have experiences due to fear or manipulation by the offender. However, recovery for this type of a trauma is possible now days if consulted an experienced and skilled therapist. The effective therapies for sexually abused victims are exposure therapy, eye movement desensitization and reprocessing therapy (EMDR) and cognitive behavioral therapy (CBT). Apart from the therapies, awareness about sexual abuse is also important so that being a part of the rape culture can be avoided (Smallbone, Marshall & Wortley, 2013).

In this scenario, the client Mary has been referred for counseling sessions due to her issues that she has been facing as informed to her general practitioner. She further reported that her cousin between ten to fourteen years of her age use to repeatedly sexually abuse and the outcome is the mental health problems that she has been facing now. Mary copes up well with the trauma earlier when her parents got to know about it and supported her, prosecuting her cousin. She was also given few counseling sessions at that time and as a result, she was adjusting well keeping the traumatic thoughts aside. However, some problems were persisting, as she could not move to another city, which she planned to join university there, difficulty engaging in any kind of intimate relationships, continuous low self-esteem and proneness towards perfectionism. Mary is 27years old now and has moved to a new flat nearby her parent’s residence and she is in relationship. Everything was going well until presently when she and her boyfriend started discussion that they should move in together. Then onwards Mary is much stressed, depressed, having extreme headaches which is affecting her work life from where she has been taking long sick leaves.

Mary's Mental State

However, from the scenario now comes the role of the therapist when working with this type of clients. Therapists role are very important, as they have to believe that is unbelievable, think that is unthinkable and they must learn to keep aside the ease of the illusions that everyone wants to hold about the world and humanity people are residing. However, this factor is very must essential in the part of the therapist to have a confrontation of self at a deeper level so that they are willing to listen to their client’s painful situations so that they realize that in this world there is nothing that one individual cannot do to another. From the therapists’ side there are certain basic requirements that must be followed are their openness as well as readiness to challenge as well as confront the private blocks. Therapists must have the ability to hear the frightfulness of abuse, to indulge and stay with the emotional pain. There must be frankness from the therapist’s part when talking about sexuality so that the client also feels comfortable. Apart from all these, adequate support is needed from the therapist’s side. First, a rapport needs to be established between the therapist and the client so that a bond of trust and care can be developed so that the client feels the comfort when facing the truth of her abuse. However, there are certain limitations and boundaries to this relationship established. While dealing with this kind of clients it is the foremost role of the therapist to encourage their clients so that they can take the control of their therapies in a positive manner. In many cases, it has been seen that if the therapist frames the normality and appropriateness of the answers to the victims then they feel greater relief from the fear of going mad. There the steps that needs to get involved with dealing with clients like Mary in order to help her recover and heal from the trauma of being abused. Those steps are as follows:

• Catharsis- after the establishment of a trusting and caring bond it is important that the victim get a change to come out with all the repressed material she has about her trauma. This can be very painful re-experiencing the trauma all over again by recalling it so at this very time a strong support from the therapist’s side is needed as the client can regress to states of doing childlike behavior and experience strong immense changes that they feel within themselves that actually make them stressed of going insane. Thus, therapist needs to be skilled enough in the areas of regression and cathartic works so that they can help the client with firmness and show them support (Webber & Wilmot, 2012).
• Cautious analysis of relationships- after catharsis the next step will be an analysis of the relationship the client has with her family members. This will bring out the problems related to adult relationships, trust, intimacy and fear from people. However, the challenge lies here where the victim needs to go towards a healed normal person to survive with a deeper responsibility for them (Kemp et al., 2014).
• Reintegration of sexuality- towards the end of the therapy the sexuality needs to be healed that has been damaged during sexual abuse. Sexual education is important, as there can be ignorance or resistance to information on the victim’s part. This part mainly focuses on the basic education, an investigation on sexual topics, and recovery of the body, fun, nurturing and self-care (Morales et al., 2016).

Sexual abuse actually make the victims acquire the feeling that their bodies are not their own and thus, the feeling of shame, depression, guilt and terror occupies them (Nelson, Baldwin & Taylor, 2012). According to the client Mary the mental health changes that she is facing are as follows-

• Depression- the feeling of hopelessness, despondency and the diminishment in the victim’s self-worth is created when there is loss of bodily independence. These feelings however, guide the victim towards depression that might range from mild to severe level of depression. In case of Mary, depression was one issue that was troubling her. It is very common that people who are sexually abused in their childhood are prone to depression in adulthood Traumatic experiences in childhood often changes the structure as well as chemistry of the brain thus, making the victim that is Mary over here become sensitized to stress thus, Mary becoming overly responsive to the environmental pressures. However, small amount of stress makes the brain outpour stress hormones and these hormones act in a direct way to produce the behavioral symptoms of depression (Gould et al., 2012).
• Anxiety- anxiety in normal individuals do not have any clear cut source of arousal but in case of sexually arouse anxiety comes from the loss of one’s own bodily independence and the fear of getting sexually abused again. Many victims develop Agoraphobia and do not want to leave their houses due to fear, others may get panic attacks (American Psychiatric Association, 2013).
• Attachment disruptions- the most challenging part for both children and others who have been sexually abused are to form vigorous attachment with others. In case of Mary, it is seen that because of her experience of childhood sexual abuse thus, she is experiencing an insecure pattern of attachment in her adulthood. She is even struggling with getting intimate with her boyfriend. Due to attachment disruptions, the victims are not that eager to build any kind of close relationship with the opposite sex (Wortham, 2014).
• Triggers- any stimuli that are matching with the offender can make the survivor remember the abused they had experienced. Triggers are thus, the stimuli. Most common triggers are violence, later abuses or intense discussion related to the abuse.
• Headaches- there is a recollection of the trauma even after many years and thus the fear of disclosing the secret of being abused brings the victims nightmare and thus, they suffers from sexual anxieties which further fuel muscular tension and emotional stress which uplift chronic headaches or migraines (Afifi et al., 2016).Mary because of her being experiences maltreatment as a child as the emotional and physical abuse that she has gone through made her experience severe headaches in her adulthood.
• Low self-esteem- Self-esteem is an importantissue for those who have been abused by a child. In this case, of Mary who is also constantly dealing with low self-esteem actually developed it back when abused as a child. This is mainly because as a child when abused after her several attempts she was unable to stop the victim, which made her ashamed, helpless and incompetent. Thus, these feelings are carried with her into her adult life and as a result reflected as her low self-esteem.
• Perfectionism- Inrelevance to Mary’s case, it has been found that she had developed a tendency towards perfectionism and that is because this quality indicates that Mary is in pain and is less probable to show their pain to others. Research has further indicated that people associated with this type of behaviors are highly correlated to anxiety, depression, stress and a high risk of suicide.
• Intimate relationship- Mary’s trust is broken once when abused in her childhood because of betrayal of trust and contraventions of personal boundaries. It is natural that her internal working model has disrupted because of the fear of being exposed, which used to create a sense of shame, guilt and confusion in her.This however, in her adult life has affected Mary to understand and interpret the motives and behaviors of others and they way she handle the stressful events of life.  
• Stress- Mary who has become sensitive to stress is due to her abused in her childhood. The stress that has been the outcome of the persistent abuse may have changes the script of the brain so even small amount of stress activated a hyper arousal response that can further result in hyperactivity, sleep disturbances, conduct disorders, memory and learning problems (Sugaya et al., 2012). This sensitivity of Mary towards stress can increase the risk in a whole agenda of stress related diseases that involves heart disease, cancer and even infectious diseases.
• Repressed memories- Keeping away thepainful memories out from the consciousness happens automatically as an involuntary mechanism because forgetting the childhood sexual abuse is an unconscious blocking that is deeply seated (Herman, 2015). In Mary’s case, it has been seen that whenever the memories of her abuse haunted her she use to push them aside. However, it can be said that Mary mainly put those memories aside because they are unconsciously blocked because its association with high degree of stress or trauma. However, the memories are not recalled but Mary but it is very clear that those memories are affecting them consciously ((Lamoureux et al., 2012).

However, sexual abuse not only has psychological scars but they leave a long lasting health issues. Victims may get bruises, severe cuts, sprained or fractured bones and torn or injured genitals. There are also chances of sexually transmitted infections that many victims do encounter with and others may become pregnant. Victims also experience disturbed health like chronic pain, sexual dysfunction, fertility issues, and reduced immunity and many other unknown aches, pains and illnesses (Frühauf et al., 2013). 

Issues related to mental health of Mary

From the point of view of counselor when dealing with a client like Mary it can be said that counseling is by far the effective factor. Counseling can be a great platform for those adults who have survived sexual abuse in childhood. It may be that the survivor first time reveals the incident of the abuse to her counselor. Victims mainly repress their incidents of being sexually abused and when they finally reveal it to the counselor, they actually feel immensely relieved. It is difficult for the victims to trust anyone. Being abused in the childhood, when they grow up they somewhere lose their confidence to trust people to avoid any kind of dangerous situation or any abusive relationship. However, counselors are trained to be dependable with respect to maintain confidentiality and reliability. Thus, when the victims experience a trustworthy experience with the counselor they starts to rebuild their capacity of trust to other human beings. After abused in childhood, when they grow up they get an intense feeling of shame that remains with them throughout. Counselor is never judgmental and so when the victim narrates her story to the counselor they started viewing things from a different angle altogether. It is the counselor’s responsibility to make the victims realize that children cannot be blamed no matter how convincingly the abuser told them they are. Thus, slowly they also feel that they were young as well as vulnerable when the incident took place. However, when the victims hear from an expert that their experience is very typical they finally feel released from shame, guilt rather feels of anger, and grief can replace it, which the counselor helps to manage safely (Champion & Collins, 2012).

According to Fergusson, McLeod & Horwood, 2013 said that childhood sexual abuse is a traumatic life event where the negative outcomes increase with the severity of abuse. There have been many cases where victims have faced abused in romantic relationships and physically abused in childhood. However, the most pathetic of them all is sexually abusing children. To overcome the trauma, fear and guilt the victims are given certain therapies that can bring them immense relief. Any form of abuses has a negative impact on the victim’s life and so they are often found experiencing emotional as well as psychological problems. Thus, depending on the assaults the treatments also varies and the common therapies and its importance are described below.

Counseling for Mary

Recovery is possible for Mary as well who have survived sexual abuse. Therapist who has experience of dealing with clients of sexual abuse can understand sexual trauma and their effects better and can give proper guidance to victims of rape and other kind of sexual abuse. However, the most important predictor of recuperation of the victim is their relationship with the therapist (Kemp et al., 2014).Thus, keeping in mind the client Mary’s condition the therapies that can be helpful for her are stated as below-

• Exposure therapy- In Mary’s scenario she can be given Expose therapy because this type of behavioral therapy is for those victims who are resulted in a specific fear after their sexual abuse. This has been designed keeping in mind that the victims will learn to manage their problematic fears through it. However, the main goal of this therapy is to design a safe environment where the client can reduce their anxiety, lessen avoidance of feared situations and can improve the standard of life of the victims. However, victims who are scared to visit the room or the area where this incident took place or fear those people wearing similar kind of clothes like the offender can be benefited from this type of an approach (Rauch et al., 2012). Thus, this can be helpful for the client Mary who can reduce her feelings of anxiety and by lessening her feared situations in life can start tackling to stay alone away from home without being anxious.
• Eye movement desensitization and reprocessing therapy (EMDR)- this is a kind of integrated psychotherapy which is designed to treat the symptoms of both trauma and posttraumatic stress. EMDR sessions however, follow a particular order of phases and the therapist uses bilateral stimulation as eye movements to guide the client handle unresolved memories from their unfavorable experiences. This can be use to confront with any number of concerns and it is also consistent with other types of therapies. Thus, this therapy uses fine eye movements to guide to rewire the brain and modify the way the victims processes the abuse (Shapiro, 2014). This kind of therapy can help Mary to deal with her stress that has occurred due to her repressed memory of childhood abuse.
• Cognitive behavioral therapy (CBT)- this therapy is a short term and problem focused form of a behavioral treatment that helps the victims see the connection between beliefs, thoughts, feelings and successive behavioral patterns and actions. Through this therapy, victims get to learn that their own perceptions influence their responses directly to certain situations. It is not a distinct treatment technique rather it is a group of therapies clubbed together. Thus, it includes cognitive, dialectical behavior and rational emotive behavior therapies. For instance Mary from the scenario discussed above who is afraid of getting into intimate romantic relationship for which she is having issues as her boyfriend asked her to shift together in the same apartment. CBT can help her greatly by making her uncover the unconscious thoughts that are causing her to avoid intimacy, allowing her to work towards a healthy relationship as well as behaviors (Resick et al., 2012).

However, therapies can guide the victims of sexual abuse to convey and process unfortunate emotions that are associated with the abuse and develop self-compassion as well as strategies for self-care so that they can manage moments of emotional overload and learn trust others again. Group therapy also help Mary by providing her with the social support so that she can cope with and modify the feelings of shame, guilt and alienation through interaction with others who have also been through similar kind of experiences. Further, it can help her regaining her lost self-confidence.

Conclusion:

To conclude this report, it can be said that sexual abuse is a kind of sexual violence where the offender is not only sexually attracted but also trying to gain power on the victim. The given case study that was selected was that of Mary who was at the age of 10 to 14 years were continuously sexually abused by her cousin. However, her family was supportive to her when they came to know about this and with counseling session, she was able to put aside her trauma and lead her life. Nevertheless, at the age of 27years, she again felt that this incident is having impact in her life. Various therapies and counseling sessions are beneficial for the survivors of sexually abused. However, it has been seen that sexually abused survivors suffers from both physical and mental health related issues. Mental health issues like depression, anxiety, PTSD, personality and attachment disruptions, addictions and triggers are common for survivors who have traumatic experiences of sexual abuse. On the hand, there are many physical health related issues as well those are obesity, headaches, Gastrointestinal disorders, Fibromyalgia and Chronic pelvic pain. Heart diseases are also said to be associated with those who have been victimized being sexually assault.

Counseling and therapies have been very effective as well as helpful for Mary who have survived childhood sexual abuse and has been repressing the incident and suffering from extreme pain, guilt and shame. Counselors are experts who have are skilled being trustworthy; maintain confidentiality and being non-judgmental. Thus, they can help clients like Mary to regain their trust on themselves and on other human. This support from the counselor can help the victims getting relieved from the pain. Moreover, they start visualizing their situation in a completely different way. The therapies that can be impactful on Mary are exposure therapy, Eye movement desensitization and reprocessing therapy (EMDR) and cognitive behavioral therapy (CBT).

References: 

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Fergusson, D. M., McLeod, G. F., & Horwood, L. J. (2013). Childhood sexual abuse and adult developmental outcomes: Findings from a 30-year longitudinal study in New Zealand. Child abuse & neglect, 37(9), 664-674.

Frühauf, S., Gerger, H., Schmidt, H. M., Munder, T., & Barth, J. (2013). Efficacy of psychological interventions for sexual dysfunction: a systematic review and meta-analysis. Archives of Sexual Behavior, 42(6), 915-933.

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