INITIAL PHASE OF TREATMENT
1. The impact of previous help and first-time clients
Previous experiences of help have repercussions which inevitably affect the new contact
for therapy. Thse need to be acknowledged. The client may come with high hopes - especially if the new therapist has been
recommended - or it may feel like a last desperate hope, or there may be no hope at all. Depending on the nature of these
earlier encounters, a wide spectrum of feelings is evident.
Other clients may seek therapy without having seen helpers previously. They may themselves
have decided to come, or it may have been suggested to them. For this group it can be the first time they have ever told anyone
this story. They may be desperate and wary of doing so.
2. Setting boundaries
Making clear the boundaries can help to make therapy a safer place. Knowling that they will
be seen regualarly, and how long a session lasts, gives the client some security. Helpers need to be clear about their own
boundaries and to communicate these to clients. External boundaries that are safe, that do not collapse when challenged
and that are clearly understood on both sides begin to act as a counterbalance to the chaos, as well as reflecting an alternative
model of behaviour.
3. Controlling the process
Control lies with the therapist when it comes to decisions about frequency of meetings and
lengths of sessions. However the clients can take charge of the use, progress and content of the time offered to them.
The client is assured that they can proceed at a pace that is comfortable, and that there
will be no pressure to disclose anything. The counsellor needs to listen carefully, to acknowledge what they have heard,
and to indicate that they have taken serious notice. The abuse of children is the abuse of power, and it is crucial that this
is no way reflected in the therapeutic process.
4. The developlment of trust
The development of trust is not simple, yet is central to the process. The guarantee of
confidentiality is important. If trust is to develop, clients need to feel they are taken seriously, and that what they say
is accepted and believed. Most importantly the client needs to feel that they won't be judged. A new client is likely to be
extremely cautious, and will be on the lookout for signs of untrustworthiness.
5. Telling the therapist about the abuse
During the first few weeks, clients begin to tell their stories. Some underplay the seriousness
of events, whilst others who carry the burden for so long can feel overwhelmed by the outpouring.
Some describe the abuse as if it happened to another person, or as if it was of no consequence.
6. The duration of therapy
Clients require different lengths of therapy and a time-limited contract is not appropriate.
Reassurance needs to be made that, although therapy cannot go on forever, it will not be withdrawn suddendly and an ending
will be negotiated.
MIDDLE PHASE OF TREATMENT
1. Facing the abuse
As trust in the therapist develops, more details of the abuse are likely to be remembered
and reported. It is common for adults abused in childhood to have only a few, vague memories. If memories have been repressed,
their return can induce painful and unpredictable feelings. Some memories occur as flashbacks which are terrifying in their
The client's agony at these times, and the complexity of their feelings, has to be addressed.
If a client states that they can't cope and that it is all too much, this should be taken seriously. It is important that
the therapist can cope with what is happening. It is supportive and helpful to acknowledge the clients feelings and
that they are entirely appropriate.
Clients may ask what they can do to help themselves. Coping strategies need to be planned
with the client, not for them. The person with most knowledge of what is helpful is the client. The role of the therapist
is to facilitate exploration and to empower, not to dictate.
2. Issues of dependency
Working with an adult survivor involves both the adult in the present, who is remembering,
and the child of the past. Clients are most likely to have difficulties moving from the dependency to independence if they
have a therapist who has difficulty in encouraging autonomy or in dealing with endings. Generally, clients move towards greater
autonomy when they are ready to do so, and when they have allowed a safe experience of dependency on the therapist.
As clients gradually begin to rely more on themselves and on those around them, encouragement
can be given. It is helpful to explore safe ways of making these changs. Relationships with others can be tried and tested
carefully, so that risks are minimized.
3. Loss, depression and anger
There are many losses endured by an adult survivor, and much that cannot be replaced. There
is never sufficient compensation for a destroyed childhood. To move on and develop as a person involves facing, grieving and
accepting the losses.
Trying to make sense of the abuse, of why it occured, inevitably evokes feelings of anger
and depression. It is essential to stress that abuse is never the child's fault, it is always the responsibility of the perpretator.
4. Challenging boundaries
While boundaries exist to hold the client psychologically, and to provide predictable containment
for their confusing experience, it is equally important to be aware of the appropriateness of moving or changing a boundary.
5. Working with the child in the adult
When dealing with an adult survivor therapists are also dealing with an abused child. Pressure
should never be placed on a client to enter their child self, and any such development should arise only from the client's
needs. Great sensitivity needs to be shown during regression, not to act in any way that is abusive or invasive.
6. Facing the abusers
One question that frequently arises is whether the victim should confront the abuser(s).
The decision varies from person to person, however it is important that clients recognize that they have both the right and
the power to decide their own course of action. The therapist's role is to assist the process: possible implications need
to be discussed and examined, and clients need to be encouraged to consider whether they feel strong enough to deal with the
FINAL PHASE OF TREATMENT
1. Who decides the ending?
The timing of termination should be decided with the client and should be agreed upon.
Some clients will know for themselves when they are ready to terminate the treatment. Others however are unable to make such
a decisive move on their own and need help to do so. There should be no pressure to terminate quickly.
2. Knowing when to end
Various factors can be taken into account by the therapist and client in deciding a date
to finish. The client's level of self-esteem is important as is the level of depression. It is unrealistic to expect depression
to dissapear entirely however it should be manageable. Reasonable autonomy needs to have been established, and the client
should have some ability to be appropriately dependent on others.
3. Uncertainties and doubts
Sometimes the decision to finish therapy can throw a client into doubt and confusion,
anxieties can surface even when the ending has been mutually agreed. The prospect of ending often helps both the client and
the therapist to focus on outstanding issues.
4. Reviewing the course of therapy
Most clients will have entered therapy with considerable mixed feelings, leaving will
produce similar feelings however for different reasons. The client has shared and explored feelings and events that were
previously untouchable and unspeakable. Reviewing the course of therapy is important. Clients who are helped to say
goodbye gain an overall perspective of the work they have undertaken; they recognise that risks have been taken, that obstacles
have been overcome, and that mistakes have been made, but most importantly they have SURVIVED!!
6. Styles of ending
It is better for the therapist and client to decide together whether to end once and for
all or whether to arrange an opportunity for a later review session. Some clients wish to make clean breaks whilst others
prefer to gradually reduce the meetings.
Whatever the decision, it should not obscure the reality of ending, which must be clearly
stated and understood. The ending needs to be appproached honestly, carefully and supportively.