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The therapeutic process

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Adult survivors of childhood abuse vary in both their motivation and capacity as well as their opportunity for psychotherapy. Given that everyone has their way of manifesting the abuse, the amount of time each patient spends in each phase is determined by each individual. In addition, the phases of treatment  are not clearly distinct at times. The stages are the initial stage, the middle stage and final stage. Although the therapeutic process may differ from one therapist to another, this gives you a guide line of what to expect as a client and the role of the therapist.

 

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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 immediacy.

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 possible consequences.

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.
 
 
 
 

(Cruz & Essen, 1994) and (Walker, 1992)