A Case of Childhood Sexual Abuse

Marna attended counselling to try to do “something” with her memories of child abuse that currently seem to be affecting her life. She attended twelve appointments over a six-month period.

In this scenario, the professional counsellor uses an eclectic approach incorporating Humanistic, Psychodynamic, Cognitive Behavioural Therapy and Abuse Literature Approaches. For ease of writing, the Professional Counsellor is abbreviated to “C”.

Background

Marna is a 32-year-old woman who was sexually abused by her father when she was a teenager. Originally the abuse started when her mother was hospitalised for three months and Marna, as the eldest daughter, had to take over many of her mother’s responsibilities.

Although she has always had some recollections of the abuse, it is not until recently that Marna has felt that it was having a big impact on her life.

She reported the major impact being on her relationship of eighteen months, where she feels she is “about to lose him”. She has not told her partner about the abuse. She also described having a very low self-esteem and stated that she “doesn’t like herself much”.

Session Details

In the first session, after hearing Marna’s overview of the problem, C described the process and the possible implications of counselling to Marna. C suggested a holistic counselling strategy for working through the abuse that included some “processing” of the abuse to try to gradually reduce the intensity of the memories, learning skills for managing the symptoms, and developing new patterns in her relationships with others.

This description included both the positive outcomes (for example, the abuse gradually having less of an effect on her life), as well as the difficulty in coping with sessions where the focus of discussion would be on details of the abuse and its impact. C suggested that Marna think carefully through these implications to decide if she wanted to go ahead with counselling or not. C also explained that even though C would facilitate the discussions and encourage Marna to participate as much as possible, Marna was in control of the sessions.

If Marna did not want to talk about a particular issue, or she wanted to end counselling, C would discuss the situation with her and support her decision. This is an essential task of the professional counsellor when dealing with issues of abuse to assist in the development of a trusting relationship, and to ensure that the client, for perhaps the first time in her/his life, has a sense of control.

Marna did agree to continue counselling and reported feeling more confident knowing that she had control over when she felt she could or could not talk about some of the “hardest” things.

Over the first three sessions, Marna gave a detailed description of the sexual abuse she experienced at the hands of her father. She minimised the sexual contact explaining that she did not think he had “penetrated” her, “just touched and fondled” her over about an eighteen month to two-year period between the ages of 13 and 15.

She stated that she had never told anyone about the abuse as she was embarrassed by it – this was her first disclosure of the abuse secret. Up until the previous year of her life, she did not think the abuse had any effect on her, except that she had some awful memories of childhood, and that she avoided as much contact with her parents as she could. Recently, however, she had begun to think that it might be the abuse that was causing difficulties in her current relationship – a relationship she desperately wanted to keep.

Marna described effects of the abuse that included “sleeping around” in her late teens, a couple of episodes of high stress where she found she was not eating for more days than she was eating, that she generally didn’t like herself much, and recurring trouble with relationships when she started to “really like the guy”. She also described times when images of her father touching her would flash into her mind, particularly during sex with her partner.

During these first three sessions, C described the impact of an exposure to trauma on people generally, and provided Marna with some written information about it to take home. C linked the symptoms of “sleeping around”, eating disorder reactions, trouble in relationships, and poor self-image to living through and coping with childhood sexual abuse. C normalised these symptoms and the impact of the abuse generally, and gave appropriate weight to the abuse that had occurred, that is, C carefully challenged and expanded on Marna’s minimisation of the events and their effects.

In the following nine sessions, Marna described any events that had distressed her in the days prior to the session. These events included nightmares, relationship problems, contact with her family of origin, and events that reinforced her low self esteem. C facilitated a thorough discussion of these events, creating a detailed image of ‘Marna’s story’.

C looked for any links between these current events and the abuse, and gradually introduced the identification of patterns that were learned in childhood and were re-occurring now.  Marna reported feeling shocked and angry when she learned about the “grooming” process of the abuse (the process that her father had undertaken to prevent discovery) and its significant part in the development of her negative patterns and beliefs.

Identifying these patterns were sometimes just an increase in Marna’s knowledge of herself, at other times they were more of a challenge to what she saw as her core beliefs. Additionally, these patterns were often identified in Marna’s relationship with C. For example, C observed in one discussion that Marna had said she liked something that C had mentioned, when her body language indicated that she did not like it. When questioned about this, Marna stated that she had not completely agreed with C but felt it would be easier if she just said she did.

After some discussion about this pattern, how her history had taught her to do this, and how it negatively affected her current life, Marna decided she would try to change it. As a result, instead of just agreeing to make things easier, Marna began to say ‘no’ to things that her partner suggested that she really did not like.

After some initial teething problems were resolved, this assertiveness increased her partner’s knowledge of Marna’s likes and dislikes and improved his ability to meet her needs. Marna also found that she began to feel more confident, to like her self more, and that her relationship was improving as a consequence of the new honesty and assertiveness.

When Marna described her abuse memories, C encouraged her by asking for elaborate details of feelings, sights, sounds, and smells – painting a complete picture of the abuse and of her childhood generally. C also cautiously expressed her own reaction to the events described to allow Marna to see another person’s appropriate anger/shock/horror/sadness at the trauma she had experienced.

When Marna reported trauma symptoms that were affecting her life (e.g. nightmares), C discussed ways that Marna might be able to manage these symptoms more effectively. C did not direct Marna with strict strategies, rather discussed what Marna had used at some time in her life that had worked with similar symptoms and encouraged her to do these more frequently. For example, Marna reported some difficulty in relaxing on the weekends.

C identified that Marna described walking and being in nature, as things that made her feel relaxed. As a result, C suggested Marna regularly walk and spend time in nature as often as she could to reduce her general level of anxiety and to improve her ability to relax when she wanted to. Marna found this an easy and enjoyable task to complete regularly and using this process, C was able to highlight her independence and resourcefulness at managing her symptoms while also keeping her sense of control in tact.

Throughout the twelve sessions, C identified Marna’s courage, normalised her reactions to the abuse, and supported her increasing understanding of trauma and its effects on her. C allowed a lot of discussion on the guilt and shame that Marna reported about the abuse, and encouraged her to appropriately allocate this blame to the perpetuator, her father.

Although guilt and shame are some of the biggest hurdles in working through a history of abuse, Marna did appear to make some progress with it. This was reflected in her increasing ability to tell those she trusted about the abuse (including her partner), and to enjoy sexual contact with her partner without the interference of memories of her father.

Overall, Marna successfully implemented regular relaxation techniques, improved her relationship with her partner through open and honest communication skills, decreased the impact of the abuse memories on her life, increased her self esteem, insight, and resourcefulness, and took some important steps in her recovery from the effects of the abuse.

Key Concepts of Therapy Applied

• An overall framework that respected and supported the client in an environment of unconditional positive regard and trust (humanistic)
• Working with the underlying belief that providing this environment will allow the client to explore their experiences and give them the opportunity to understand themselves better, change their patterns, and make sense of the situations at hand (humanistic/psychodynamic)
• Looking at the here-and-now in the counselling relationship and identifying and working with the patterns observed (psychodynamic)
• Ensuring the client feels in control and safe (abuse literature – eg. J.L. Herman)
• Providing education on trauma and child abuse (abuse literature/CBT)
• Normalising the client’s reactions and behaviours (humanistic/CBT/abuse literature/psychodynamic)
• Application of relaxation techniques, although using the resourcefulness of the client rather than prescribing strategies (abuse literature/CBT)
• De-sensitisation to the abuse through telling and re-telling of the story (abuse literature/psychodynamic/CBT)
• Fostering client insight (psychodynamic)
• Improving communication skills (CBT)