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Childhood Sexual Abuse - Providing a service to survivors

In this article psychotherapist Jessica Wooliscroft describes her experiences researching into the provision of services to people traumatised by abuse in childhood.

My colleague Helen Ketchell, (a GP Counsellor) and I, along with other members of the then East Cheshire Psychology Department (…now disbanded due to health care financial ‘savings’), the local Citizens Advice Bureau and Community Mental Health Team had worked together for many years to try to raise the profile of childhood sexual abuse and to improve awareness within the NHS of its traumatising effects. We were able to secure £12,000 funding from what was  then the Strategic Health Authority (since disbanded to save money) to set up in depth training and supervision groups to tackle the issue of childhood sexual abuse and how best to respond to people disclosing historical abuse. Over a period of two years we trained and supervised around 350 NHS staff in Cheshire and Wirral NHS Trust. Helen Ketchell and I then carried out some research to find out how the training had affected staff attitudes to working with survivors of childhood sexual abuse. The results revealed that most of the staff increased in confidence and competence, but also were hungry for more training and ongoing supervision.

As I reread our research article recently I noticed that while there is now a lot more openness about the subject and survivors of childhood sexual abuse (CSA) are more likely to be believed by the police and health professionals, there are still times when, unless the evidence is overwhelming, it just seems to be too difficult for establishments to take on the full implications of what is happening to children in our society.

Fairclough (2001), who uses a depth research technique called Critical Discourse Analysis (CDA), suggests that critical discourse analyses should follow these stages:

  • identify the problem
  • identify obstacles to the problem being tackled
  • consider whether the social order needs the problem
  • identify ways past the obstacles
  • reflect critically on the analysis

By using this research structure as a guide, it is possible to tease out some of the dynamics that underlie our society’s reluctance to tackle childhood sexual abuse.

Helen Ketchell and I originally identified the research problem as a lack of NHS staff competence and confidence in working with the survivors of CSA. A training programme was set up to tackle this at introductory, advanced and supervisory levels. The results showed that specialist training can alter staff attitudes and improve their competence and confidence.

However, the problem of CSA is not a new phenomenon. Given its long history, high prevalence rates, and the profound impact it has on psychological and physical health, it is worth asking why NHS staff have remained so ill informed and nervous about working with survivors.  What are the obstacles that prevent NHS staff from recognising and understanding traumatic abuse?

We proposed that the following obstacles hindered the resolution of this problem:

  • No / little training for working with CSA
  • CSA is a taboo area that staff, just like the wider population, do not want to ‘see’
  • Acknowledging the high prevalence of CSA would entail that staff, like the wider population, would have to accept a more challenging or ‘difficult’ perception of our society
  • Acknowledgement also requires staff to summon the energy to take action, which is difficult when they are already stressed and overwhelmed
  • Taking appropriate action may bring staff into conflict with NHS management due to lack of resources
  • A paradigm shift towards the trauma model challenges both the medical model and current power dynamics. Staff may be disbelieved and stigmatised as ‘overreacting’.
  • There is a huge need for resources in this area
  • Child Protection implications are at times emotionally challenging and difficult to implement
  • Disclosure rates might increase, leading to an even greater draw on resources

Thus there are many powerful forces involved in the maintenance of the current dominant discourse. These forces affect how presenting symptoms are interpreted.

Although it has been known since World War I that battle trauma can cause amnesia (Van der Kolk 1996), many disclosures of the trauma of CSA by adults who remember the abuse after a gap of many years, are disbelieved. CSA survivors are not ‘allowed’ to have suffered amnesia but instead their disclosures are seen as the products of a ‘false memory syndrome’. Samantha Warner (2003a) has written about CSA in the context of patriarchy and Alice Miller (1983) has described how a ‘poisonous pedagogy’ institutionalises violence and child abuse as a ‘normal’ part of childrearing (note the debate about whether parents should be ‘allowed’ to smack their children). These attitudes work together to make childhood sexual abuse an invisible problem.

Because CSA is so taboo and shocking, it’s disclosure tends to have an explosive effect. Disclosing CSA causes ripples. The survivor’s family may be held together by a collection of such secrets. Disclosure can seriously challenge the family structure. Families consequently shun many survivors. Abusers are able to abuse because they are in positions of power within a family structure. The power structure within the family then is also challenged. Some abusers hold positions of power and influence in the wider community, disclosure is threatening to the status quo.

At the very worst extreme, when the traumatised person can no longer cope with their abuse, they can find themselves at the mercy of a health system that may label them as mentally ill rather than multiply traumatised. There now follows a lengthy extract from Richard Bentall’s award winning book “Madness Explained” (2003). This extract nicely illustrates, not only research regarding the prevalence of CSA, but also how the different discourses about mental illness and childhood abuse battle with each other for dominance (Bakhtin 1986).

‘Some studies have examined the relationship between psychosis and sexual and physical abuse. Investigations of this sort are quite difficult to carry out. To begin with, there is considerable disagreement about the best way of defining abuse. Depending on the definition used, a larger or smaller proportion of the population can be said to be victims of assaults. Moreover, evidence of assault is usually obtained from descriptions given by patients during interviews. Recent debates about whether patients ever experience false memories of abuse testify to widespread suspicions that these kinds of descriptions are sometimes unreliable. However, it is also worth remembering that victims sometimes have powerful motives for not reporting this kind of trauma. They may be embarrassed or ashamed about what has happened to them, or expect others to blame them for allowing themselves to be victimized.

Despite these difficulties, there is consistent evidence that a history of physical or sexual abuse is unusually common in psychotic women. In a review of research on this topic, American psychologists Linda Goodman, Kim Mueser and their colleagues were able to identify thirteen adequately conducted studies. For the purpose of their review, they defined physical abuse as acts ‘intended to produce severe pain or injury, including repeated slapping, kicking, biting, choking, burning, beating, or threatening with or using a weapon.’ They defined sexual abuse as, ‘forcible touching of breasts or genitals or forcible intercourse, including anal, oral or vaginal sex’. The highest estimates of abuse were obtained in those studies that Goodman and her colleagues judged to be the most meticulously executed. Across the thirteen studies, between 51 and 97 per cent of women reported some form of physical or sexual abuse in their lifetime, suggesting that perhaps the majority of mentally ill women have been victimized in this way”. (Bentall, 2003: 478-479)

As can be seen from the above extract, lack of recognition of childhood abuse may be ‘a problem that society needs’ (Fairclough 2001), in order to maintain the status quo. However, there are ways past these obstacles, and as we know, dominant paradigms in society can and do change. Police Operation Ore, for example, locating paedophiles using child pornography on the Internet, has helped to publicise the scale of abuse. Some perpetrators are recorded as having ‘millions’ of photographs of child abuse on their files. Each of these photographs is evidence of a sexual assault on a child.

One of the best ways forward is through investment in education. Health care staff training must not be sporadic and temporary but should be integrated into services at all levels. Training is pointless without team support to apply it, so managers and teams need to work together. Supervision is vital, not only to improve skills but to meet the duty of care towards staff. Staff working with trauma are at risk of vicarious traumatisation, which is ameliorated by good quality supervision and team support. Institutions whose staff are working with trauma such as CSA need to take seriously the powerful forces that can be unleashed. Disclosures may bring about complaints and legal action. Staff may be put at risk. There are potential knock on effects regarding health and safety, staff recruitment and retention. For this reason, training needs to include managerial staff as well as clinical staff so that implications can be planned for.  Just as a fire lecture does not take place once every five years to a handful of staff, so training for working with CSA must be offered regularly to all staff appropriate to their responsibilities.

We leave the last word with the trainees on our courses. These are direct quotes from feedback forms that were filled in by the participants and do indicate how health care professionals ranging from Nurses to counsellors to art therapists even some consultants felt about this issue.

  • “We need more resources; we can only treat the tip of the iceberg”
  • “I do not feel supported!”
  • “Doctors often tell clients to stop therapy or change therapists when things get difficult”
  • “I want to integrate the excellent theoretical background with my therapeutic practice”
  • “This work is difficult and emotionally demanding”
  • “I have made changes to my practice and supervision since starting this course, which feels very positive”


REFERENCES AND FURTHER READING.

Bakhtin, M. (1986) Speech genres and other late essays, C.Emerson and M. Holquist (Eds) Austin, University of Texas Press,

Bagley, C; Ramsey, R. (1985) Sexual Abuse in Childhood: Psychological outcomes and implications for social work practice. Journal of Social Work & Human Sexuality, 4, 33-4.

Bentall, R. (2003) Madness Explained, London, Penguin.

Briere, J. (1996) Therapy for adults molested as children, 2nd Edition, Expanded and Revised. New York:Springer Publishing Co.

Briere, J. (in press) Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model, in J.E.B. Myers, L.Berliner, J.Briere, C.T. Hendrix, T.Reid and C.Jenny (Eds) The APSAC handbook on child maltreatment, 2nd Edition. Newbury Park, CA: Sage Publications.

Day, A; Thurlow, K and Woolliscroft, J. (2001) Working with childhood sexual abuse: a survey of mental health professionals, Journal of Child Abuse and Neglect 27, 191-198.

Fairclough (2001) Critical Discourse Analysis: welfare reform and New Labour in M.Wetherell, S.Taylor and S.J.Yates (eds) Discourse as Data:A Guide to Analysis, Lonon, Sage.

Finkelhor,D.  and Browne, A. (1985) The traumatic impact of child sexual abuse: a conceptualisation. American Journal of Orthopsychiatry, 55, 530 –541.

Foucault,M. (1978) The history of sexuality, volume one :an introduction. Middlesex: Penguin.

Foucault (1980) Power/Knowledge: Selected writings and other interviews 1972 –1977, C,Gordon (Ed,) New York, Pantheon.

Habermas (1984) Theory of Communicative Action Vol 1, London, Heinemann

Herman, J. (1981) Father – daughter incest. Cambridge, MA: Harvard University Press.

Goodman,L.; Rosenberg,S;Mueser,K and Drake,R. (1997) Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions, Schizophrenia Bulletin, 23: 685-96.

Gramsci,A. (1971) Selections from the prison notebooks, New York, International Publishers.

Herman, J.L. (1992a). Trauma and Recovery. New York: Basic Books.

Janoff-Bulman, R. (1985) The aftermath of victimization: Rebuilding shattered assumptions. In C.R. Figley (ED.), Trauma and its wake: The study and treatment of post-traumatic stress disorder (pp.15-35). New York: Brunner/Mazel.

Janoff-Bulman,R. (1989) Assumptive worlds and the stress of traumatic events: Applications of the schema construct. In Stress, coping and social cognition (Special Issue), Social Cognition, 7, 113-136.

Mendel, M. (1995) The Male Survivor: The Impact of Sexual Abuse, London, Sage.

Sanford, L. (1991) Strong at the Broken Places, London, Virago Press.

Messler Davies, J; Frawley. M. (1994) Treating the adult survivor of childhood sexual abuse: A psychoanalytic perspective. New York, Basic Books.

Miller, A (1983) For your own good. New York: Farrar, Straus & Giroux

Nijenhuis, E; Van der Hart, O; and Steele, K. (2004). Trauma-related structural dissociation of the personality. Trauma Information Pages website, January 2004, Web URL: http://www.trauma-pages.com/nijenhuis-2004.htm

Ross (1989) Multiple Personality Disorder. New York, Wiley

Van der Kolk, B; McFarlane,A; Weisaeth,Lars (Eds) (1996)Traumatic Stress, New York, The Guilford Press.

Van Dijk, T.A. (1993) Principles of critical discourse analysis, Discourse and Society, vol.4 pp. 249-283

Warner, S. (2003a) Disrupting identity through Visible therapy: A feminist post-structuralist approach to working with women who have experienced child sexual abuse, in P. Reavey and S.Warner (Eds) New feminist stories of child sexual abuse: Sexual scripts and dangerous dialogues, London: Routledge, pp.167-186.

Warner, S. (2004) Contingent morality and psychotherapy research, in psychotherapy Section Newsletter No.36, The British Psychological Society.

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