by Chris Yarrow. Email: chris_yarrow@hotmail.com.
I thought carefully about describing someone as a “survivor” of sexual abuse as it can be construed as minimising the internalised dysfunction that can occur as a result of the long-term and pervasive nature of the abuse. So it is used in this essay as a term rather than an empirical description.
The damaging experience of childhood sexual abuse cuts across all socio-economic and cultural barriers and can permeate adult life with its haunting effect. In my experience as a counsellor in both Private and G P practice, I have witnessed this effect contributing to a developing psychopathology of depression, self-harm and eating disorders as survivors attempt to pathologically soothe their pain. Others attract abusive partners as an unconscious repetition of their earliest experiences. Hollis (1998) describes this as an internalised template of an earlier abusive experience in which one has felt powerless thus, “unwittingly, they conspire against themselves to remain not only with, the [current] abuser but with the powerlessness of childhood” (1998:23). Other clients present with stress and anger management problems, inability to relax and hyper-vigilance, often ‘scanning’ the environment for perceived danger.
Although individual therapy has a central part to play in the recovery process, it is enhanced and complemented by group treatment as an alternative or adjunctive treatment modality. Indeed, Marrone (1998) states that “it is not merely an economical substitute, nor a short cut, it demands to be appreciated as an essentially new orientation in clinical practice” (1998:172). However, a group experience is not a panacea for all survivors. If their internal resources are not strong enough, a group experience can be too overwhelming and thus be counter-therapeutic. Corey & Corey (1997) emphasise that “it is critical that members possess ego strength to deal with the material that will be explored during the sessions” (1997:392). Further selection criteria to ensure readiness for joining a survivors group will be discussed later.
Healing from childhood trauma is something that no one should have to go through alone. However, when considering the most appropriate group which meets the individual needs of the survivor, two groups appear to exist. A self-help or peer support group (heterogeneous) and a professionally led therapy group where members are selected by way of a specific criteria (homogeneous).
During my counselling training, I attended a support group for female survivors of childhood sexual abuse where I observed both the positive and negative aspects of this kind of support. It was an open group and the meetings were conducted by the members themselves who assumed the leadership role on a rota basis. Tasks varied from supporting an individual member, particularly if intra-personal material had been stimulated by the week’s events, to designing a banner which, by involving all members, enhanced the group cohesion. Indeed, at times there appeared to be a sense of identification and emotional closeness, a seemingly curative component which emerged from this supportive environment where each member shared a common bond.
However, at times, particularly if several members were depressed, each would heatedly argue that their experience was the defining experience. When this occurred, the intervention of a skilled facilitator to provide effective support would have not only been useful but necessary. Indeed, Page (1999) warns that without professional facilitation “shadow material in such a group can be explosive and destructive rather than constructive" (1999:83). Therefore, a member’s destructive potential, which may have remained dormant, is more likely to emerge in abusive anger. What I have learnt is that a major disadvantage of self help groups is that many have no built in safety mechanisms to contain these destructive behaviours. With no supportive element in place, the affected member is left uncontained and unable to make sense of what has happened. It must be acknowledged, however, that validation and support from self-help groups can enhance a survivor’s confidence to enter a more specialised therapy group in which to resolve their trauma and reclaim their lives.
I shall now discuss what I consider to be two of the most important considerations for the formation of a specialist group. These are screening the prospective members of the group, and the essential group leaders/facilitators' qualities.
Corey & Corey (1997) view screening “not as a highly objective and scientific process but as a rough device for getting together the best clientele for a given group” (1997:115). They prefer to talk to the prospective members, giving them information thereby orientating them to the group in order for them to be pro-active in deciding whether the group would meet their specific needs.
Bion (1961) does not encourage interviewing prospective members of a group however, I do not share his view. I consider that it is important for prospective members to informally meet the group leader(s), in order to both screen for the appropriateness of group membership and also eliminate survivors exhibiting specific problems. I concur with the view held by Vinogradov and Yallom (1988) that clients displaying general symptomatology including psychosis, suicidal ideation and actively using chemical substances need to be excluded from therapeutic groupwork. It is also important to assess levels of coping skills, willingness to participate and goals for seeking therapy in order that each member can participate fully and group cohesion is achieved.
However, I would also suggest that it is not beneficial to include members who ‘think’ they have been abused, or are struggling to remember the details. There is a danger that they risk concretising thoughts into memories after hearing others' experiences.
I shall now discuss the group leadership. Corey & Corey (1997) state that “who the leader is as a person is one of the most significant variables influencing the group’s success or failure” (1997:63). Additionally, leaders should be able to communicate the core conditions of genuineness, regard and empathy within a democratic leadership style.
I consider that having shared the same experience is not necessarily a pre-requisite to leadership nor does it suggest more competence. Leaders will be just as effective if they possess an in-depth knowledge regarding the etiology, treatment and long-term effects of childhood abuse.
Although this work can be rewarding, due to its intense nature, it can also be draining and stressful listening to client material, therefore leaders are likely to face their own personal stress. These may include psychological vulnerabilities with each leader having their own idiosyncratic triggers which can be provoked and may threaten to overwhelm them. Some leaders may also become affected by certain members of the group and project their own problems and personal issues onto the members whom they perceive to be a threat either to themselves or their leadership style. It therefore cannot be emphasised strongly enough how essential it is for the leader to be working within a supportive milieu which includes good supervision and personal therapy. Although individual therapy and supervision is helpful, sometimes group support has a distinct advantage. Firstly it mirrors the process being offered, but secondly it provides a container for any stressful feelings being experienced by the leader and help them to navigate transference and counter transference dynamics successfully and separate their own processes from those of the group members. Other transference and counter transference issues within the whole group dynamics will be discussed later.
I shall now explore some of the special considerations which need to be taken into account during the process of this specialist group. Douglas (1995) refers to group processes as “patterns of group functioning which develop over a period of time” (1995:44). Space does not allow full discussion of all these functions, however, I shall be concentrating on the following. Firstly the concept of norms (Douglas, 1995) with particular emphasis on boundaries. Secondly the transferential aspects, which occur at any stage of the group process and which Yalom (1995) considers are omnipresent radically influencing the group discourse. Lastly the concepts of translation (Foulkes 1964) and mirroring (Foulkes and Anthony, 1957) to illustrate how other group interactions are also therapeutically helpful.
From the outset, one of the leader’s primary tasks is to facilitate the formulation of a group in which members can experience a safe environment and ultimately a trusting emotional connection both with each other and the group as a whole. In order to achieve this, when a group first starts working together, a set of ground rules or ‘norms’ Douglas (1975) needs to be established. These norms, or boundaries form the working alliance and provide the group with its safety and structure. Some are arbitrary, others are decided by the group via a democratic process. Important boundary issues which need to be agreed are the extent and limitations of confidentiality and commitment to the group meetings. Others are safeguarding the physical and emotional safety of each member, and emphasising that no physical violence of verbal attack will be tolerated. Another boundary issue which needs to be considered is that of touch, as it remains a controversial area when working with survivors. However, I consider that holding both metaphorically and literally, especially if instigated by the client, has tremendous reparative value. This is especially true within a group context as it is witnessed by others and not in danger of misinterpretation. I consider that the introduction techniques outlined in the Sresss Management Training, such as clients introducing themselves and the ball and name game is an excellent way of helping clients reduce tension and anxiety.
The middle or “storming” stage (Handy, 1976) in the group process is when members are most likely to express conflict and anger that I consider maybe rooted in transference issues. Indeed, many of the problematic behaviours witnessed at this stage, are rooted in what Tudor (1999) describes as “multiple transference which acknowledges that the patient’s transference manifests itself in and onto the multiple relationships in the group and not just with/onto the therapist"(1999:8). Another illustration of how this projection can occur in a group is when unwanted, dangerous thoughts and feelings are pushed out of the self and put on to others. An example of this is scapegoating, which is a method by which the group can discharge anger from any source onto a member or members, and if not addressed can threaten the group functioning. Yallom (1995) gives an excellent example of the essential posture of the therapist which radiates “concern, acceptance, genuineness, and empathy” thereby providing a container for these projections.
Berne (1963) also suggests that every member carries within them an image of the group based on previous group experiences such as their family of origin. This subjective image as a group imago is a mental picture of how a group should be, based on previous experiences whether “conscious, pre-conscious or unconscious” (1963:321). Therefore by processing these transferential patterns and habitual ways of relating, each member has the opportunity for new personal growth and which allows for a unique configuration of previously assimilated familial roles. I consider this to be especially important when counselling survivors of childhood sexual abuse.
Foulkes, the founder of group analysis, emphasised the therapeutic nature of communication between group members as they attempt to translate their symptoms into meaning. I am interested in Foulkes’ interpretation of ‘translation’ when he states, “a group is therefore obliged to translate symptoms into meaning and to transform the driving forces which lay concealed behind them into emotions, desires …. experienced in person. While doing so the members learn a new language …. and the capacity for insight and communication grows” (1983:176).
Another important aspect of group therapy for survivors is that members display evidence of neurotic symptoms which are manifest in their failure to either enter into or maintain new satisfying relationships within the group. He goes on to explain that “the language of the symptom, although already a form of communication is autistic. It mumbles to itself secretly, hoping to be overheard; its equivalent meaning, conveyed in words, is social” (1983:259-60). The autistic symptom in a survivors' group situation is the overwhelming impact of sexual abuse. Members often do not know if their feelings of confusion and isolation in not being able to form relationships is linked to their abusive experience, or simply a symptom of their perceived madness.
The similarity of homogeneous group members offers each person a mirroring of her experience which can be both validating and containing. Foulkes and Anthony (1957) describe this process as particularly powerful. Each member sees mirrored back a sense of normality and not how they may be feeling inside; that the abuse is not, as one client told me, tattooed on their forehead and therefore does not 'show'. They have met and formed relationships with 'real' women in the group and are no longer isolated in their suffering.
It is prudent at this point to reflect on the high levels of stress I have observed in the clients who have previously suffered in abusive relationships particularly in childhood. Carroll (2004) has highlighted how chronic abuse in childhood can lead to a disregulation of the finely balanced feedback systems including cortisol regulation. She states, “ a trauma response, similar to the terror of the “no way out” situation (when sympathetic and parasympathetic are both hypo) occurs when the attachment relationship has become abusive … and the … child is unsupported when faced with high levels of … fear” (2004:S5:2). In adulthood this can lead to low stress thresholds, diminished capacity to evaluate others actions and problems with anger management. In order to alleviate these systems Carroll (2004) highlights not only the need for attunement from the therapist to the clients in both individual and group treatment sessions in order for them to feel understood, but also the importance of relaxation which I will now discuss.
The Stress Management has helped me to incorporate to good effect, the relaxation techniques woven through this excellent course and apply them to the above client base. Relaxation exercises such as relaxed breathing and progressive relaxation (Jacobson, 1958) are useful tools to employ the parasympathetic nervous system thereby reducing heart rate and stress levels and enabling the clients to relax. Indeed, Corey & Corey (1997) describe how victims of childhood sexual abuse fear ‘losing control’ over their emotions and emphasise that a considerable amount of time needs to be allocated to teach deep breathing and relaxation exercises to help clients release pent up emotions. Excellent relaxation techniques such as these can be anti-stress weapons that clients can always carry with them to enable them to deal with any stressful situation as it arises particularly when the group has ended.
To bring about lasting change, as an adjunct to the relaxation therapy, I consider that Rational Emotive Therapy (Ellis, 1962) has a lot to offer to help clients change their irrational beliefs, such as the ‘musts’ ‘oughts’ and ‘shoulds’. In the groups I am discussing, where the members of the group are distressed in different ways, each member can be encouraged to express what they are telling themselves just before they felt the symptoms of stress provoking anxiety. It also helps to explore what they may be doing to amplify or exacerbate the problem. By using Rational Emotive Therapy clients can be shown how to dispute their musturbatory beliefs i.e. “where is the evidence for this belief?” Disputing logically the demands that clients are making on themselves it becomes possible to construct a new effective rational thought, i.e. “what I have experienced is awful, I do not like how it has effected me and I hope to change it for the better. But it is not so awful and terrible that it will define who I am for the rest of my life, I can take the power back”.
In conclusion, I have explored some of the special considerations which would have to be taken into account in the formulation and process of a specialist group for survivors of sexual abuse and how stress management training with its emphasis on relaxation can be successfully incorporated. It also needs to be acknowledged that the ending of such a group is sometimes difficult and needs to be carefully managed throughout the group process as suffice to say this phase of the group process can be characterised by group members recalling other significant separations and losses in their lives. Space precludes me from exploring group endings in more detail but I have found it interesting to note that little seems to have been written on endings in groups with Yallom (1995) himself devoting less than two pages to this topic. However, on a positive note, as the group reaches its ending it is also important to re-visit and emphasise that an important goal of therapy is that a survivor will be able to identify the impact of his/her abuse as only part of their life's journey and not its totality; ideally he/she will be able to see himself/herself as "someone who was abused as a child" rather than a "survivor of sexual abuse".
References
Berne, E. (1963) The Structure and Dynamics of Organisations and Groups, New York:Grove Press.
Bion, W. (1961) Experiences in Groups, London:Routledge
Carroll R. (2004) Handbook from Emotion & Embodiment Conference, London.
Corey, G and Corey, M. (1997) Groups Process and Practice, Pacific Grove, CA:Brooks/Cole.
Douglas, T. (1995) Survival in Groups, Buckingham:Open University Press.
Ellis, A. (1962) Reason & Emotion in Psychotherapy, New York:Lyle Stewart.
Foulkes, S., (1964) Therapeutic Group Analysis, London:Allen/Unwin.
Foulkes, S.H. & Anthony, E.J. (1957) Group Psychotherapy:The Psychoanalytic Approach, London:Karnac.
Foulkes, S.H. (1983) Introduction to Group-Analytic Psychotherapy, London:Maresfield Reprints.
Handy, C. (1976) Understanding Organisations, Middlesex:Penguin.
Hollis, J.(1998) The Eden Project, In Search of the Magical Other, Toronto:Inner City Books.
Jacobson, E. (1958) ‘Progressive Relaxation’ Chicago:University of Chicago Press.
Marrone, M. (1998) Attachment and Interaction, London:Jessica Kingsley Publishers.
Page, S. (1999) The Shadow and the Counsellor, London:Routledge.
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Vinogradov, S & Yalom, I.D. (1988) cited in Stress Management Training, The Stress Consultancy, Yorkshire.
Yallom, I.D. (1995) The Theory and Practice of Group Psychotherapy, New York:Basic Books.
Yallom I.D. (1995) cited in Stress Management Training, The Stress Consultancy. Yorkshire.