Working with a client population generally known as sexual trauma survivors is very challenging work. Sexual trauma survivors are a very complicated mix of fragility and pain, along with an incredible will to live and survive whatever trauma they have encountered. Much of what survivors do is unconscious and reactive. There are a complex set of behaviors that are common to survivors of significant amounts of trauma. These skills will vary depending on the age of the individual, when the trauma occurred, how long it lasted, how comprehensively it encased their life, and whether or not the perpetrators of the trauma were persons in their life who should have been trustworthy.
As a therapist, you will encounter many clients who have experienced various forms of sexual trauma. Are you a sexual trauma survivor is a question you should always ask in a very direct manner in the very early stages of therapy. Clients may have experienced overt and covert forms of molestation. They may have been raped and tortured, and/or they may be victims of incest or abuse from “trusted” figures. It is really frightening to learn things that some people are able to do to children. As a therapist, you need to be able to hear these stories without becoming so sickened, or so angry that your own emotions overwhelm you. If you become angry at what you hear (and you WILL) you must be very careful to identify to the client that you are angry, but that you are NOT angry with them for what they experienced. You are angry at whoever was able to hurt a child and do the things that were done to them. It makes you very angry when children are hurt in any way by anyone. You need to further reassure them that you do not need them to be angry with the perpetrator. Your anger is your own, and you understand that they may not be angry at the person who hurt them. You must say these things softly, gently, directly, and repeatedly. Your client will not be able to hear them, nor accept the content of the message initially, but you must deliver the messages of your anger at the perpetrators quietly, consistently, affirmatively and repeatedly. If your therapy works, and the client manages to get better, having given them these messages will work to solidify your own trustworthiness and cement their ability to reality test the feelings and messages they receive from others.
You need to learn about abusers and how they operate when children are sexually molested. How are they connected to the victim and how do they perpetrate the abuse? What messages are given to the children to frighten them, blame them or seduce them into feeling some level of responsibility and ownership for what has happened? Were others that were important to the child threatened? It is common for the victim to hear, “If you tell, no one will believe you. I will find out if you tell and come back and kill your puppy.” I have had clients who were told this. I had other clients who were told that their mom, dad or sibling would be killed. Some clients were told that no one would believe them, but if they talk about it, they would be taken away from their families because they were such bad children. No one would want to love them or live with them once it became known how nasty and bad they were. Children who are given these messages, especially when something painful and shameful is happening, tend to believe them. They internalize the responsibility and the fear, and they learn to do something in order to survive the awful things that they are enduring.
One of the most important skills for the survival of trauma is the ability to dissociate. Dissociative disorders like amnesia, fugue or even dissociative identity disorder are amplified versions of a defense mechanism that every one uses. We all dissociate at some time. Dissociation is the ability to “go away” while something unpleasant, frightening or painful happens. Trauma survivors, especially those who live in systems where trauma is constant and the surrounding environment is always dangerous and frightening, learn how to “go away” whenever they need to. In its extreme forms, they do not feel pain, they do not remember the events and they do not experience what is happening to them.
If you are working with this population, you will need to learn to recognize when someone dissociates. What does it look like? What does it sound like? How do you know that they have just thrown a switch and “gone away?” What behaviors can you see or experience that indicate to you that someone is not feeling what is happening in the moment? Sometime clients develop a repetitive behavior like a cough, crossing their legs or tapping their fingers on a desk. Using these physical cues, they manage to “disappear” while an unpleasant or frightening event is taking place. Their bodies do not go away, nor resist what is happening, but their “self” goes away. It returns when the situation is over and the crisis is resolved. For others, it is less obvious. When you have spent enough time with them, you will recognize a change. The focus of their eyes changes from good eye contact and actively responding to the flow of the conversation, to eyes being half glazed over and a loss of focus in the conversation. They will continue to participate in the conversation, but their “self” will not actually be there. They may not remember what was said when the come back after the danger or anxiety has passed. The danger can be physical, like being in the presence of a “trigger” that reminds them that some trauma is about to happen (sometimes called a flashback.) The trigger may be a sound, a story or some physical sight or event that causes them to flashback to a previous experience and to shut down or disappear within themselves.
In therapy, once you have established a trusted relationship with the client, you can begin to “notice” their dissociative episodes. Gently say to them, “It seems to me like something just changed and that you went away somewhere. Did It?” They will typically start out by saying, “No, you are wrong. I am right here and nothing changed.” Accept what they tell you and say, “Ok, I accept that. I will always believe you and I believe you now. However, usually when I see these signs, it means that someone has dissociated. I need to know how you work, so I need to be able to ask you about it whenever I notice this change in you. You just keep being honest with me and I will eventually get it right. Is that OK?” If they feel safe, they will agree. As time goes by and you continue to work with them, you continue to point out whenever they shift out of focus and go away. Ask them if they just did that whenever you see it, and eventually, they will begin to recognize that indeed, they have shifted out of focus. At that point, do not gloat or laugh and say, “See, I told you so!” Instead, you thank them for trusting and for listening. Then ask them, “What do you remember we were talking about just before you went away?” They may not remember. Remind them what it was and ask, “Is there anything you remember about that topic or event that you want to talk about?” Or ask, “How do you feel when this topic or event is brought up?” You gently begin to accurately reflect back to them what you are getting from them. These messages may be that they are angry, afraid, sad or hurt. You reflectively listen to these messages by “hearing” them and by “reflecting” them back to the client accurately. Ask if they recognize whether or not this message is an accurate understanding of what they are feeling. Do this over and over, no matter where the story goes. Eventually, dissociative clients will begin to “feel” and “remember” when this happens, they will lose the ability to dissociate and go away from unpleasant memories.
When they are able to remember and share their feelings and experiences, you have to be very gentle and strong at the same time. They need you to not be frightened, disgusted or over the top with your own anger. They need you to support them, give them messages that you are proud of their ability to survive, that you know absolutely that they are not guilty of being bad. You honor that they were able to do whatever was necessary in order to survive, to get to this place. Then, teach them that the past is not a prologue and they can change the script of their lives and heal. They cannot change what was done to them. But, they can heal and not spend their lives as victims who constantly have to dissociate in order to survive.
As a therapist you must remember that your primary job in working with dissociative trauma survivors is not to prove anything. You are not an agent of the court, it is not your job to catch perpetrators or punish them. Your job is to help the client heal, to get strong and be able to live their lives free and healthy. It is not your job to pursue revenge or punishment. Your job is to relate to the client and help them get strong enough to heal themselves from the horrible wounds of the trauma they have experienced.