Treatment plan for working with sexual abuse - Bob Cooke

Treatment plan for working with Sexual Abuse.

Many years ago I wrote an article for Psychotherapists and Counsellors on how to work with people who have been sexually abused and traumatised at a deeper level.               This blog is taken from part of the article

People presenting from sexual abuse trauma will present with some  or more of the features below.

1— fear and mistrust

2— panic attacks and anxiety

3— nightmares and flashbacks

4— poor self image

5— self esteem issues

6— A feeling of self worthlessness and no value

7— depression

8— cumulative trauma

9— paranoia

Treatment plan for working with Sexually abused clients.

First stage— Establishing a strong working alliance between clients and therapist. This may take many months and in fact may be a hallmark of the psychotherapy process. But it is  essential  in terms of psychotherapy process being successful. The psychotherapist will have to be patient and earn the client’s trust.

The second stage– Retrieval of memory— in this stage the Therapist will concentrate on phenomenological Inquiry ,this means helping the client going further into their history and helping them understanding of how the past is played out in the  present- to make connections.

As she makes these connections she will be hopefully allowing yourself to retrieve memories that she had cut off from in order to protect herself from feeling and remembering the abuse.

The third stage—-  The Emergency stage– it is characterised by the client getting in touch with and emotions, and often a flood of emotions.

In this stage  the therapist needs to be fully supportive, and be prepared ,to offer more therapy sessions and indeed be more accessible for the client as she works through her confused emotions.

The fourth stage— New  decisions and Integration  — in this stage new decisions are taken and there is more integration for the client. She comes from a more integrated adult ego state

The fifth stage— Endings and  Termination—- in this stage we give time for the client to end with the therapist and the therapist to end with the client. This stage must not be rushed and a full account of the whole process needs to be reviewed and celebrated.

On a final  point, please note that though this treatment is written in order, it is in fact ,a morefluid process where the Therapist may, with the client visit, many different stages, at different times, and indeed may re-visit the particular stages more than once for more therapeutic work to be done.

Measures of Ego Strength

This is a short blog on the measures of ego strength.  In other words, what makes up the adult ego state in the model of transactional analysis, what makes up the robust sense of self and in many other models, what makes up the mature self?  In other words, how do we judge or assess the strength or robustness of the mature self or in TA, the adult ego sense of self.

Ok, so I’m going to give a list of nine ways that we can assess the level of maturity of the adult ego state or the mature self.  

1. We look for the ability or the capacity of the mature adult to establish and maintain mutually helpful and supportive relationships at home, at work and at leisure.

2. The ability to look after essential needs for food and shelter and to be self-supporting.

3. The capacity to adapt and adjust to relationships at home, at work or at leisure which are difficult and upsetting.

4. The capacity to derive interest and satisfaction from the performance of skills and variety of setting.

5. The capacity to maintain a realistic sense of self-confidence and self-esteem.

6. The capacity to cope adaptively with change, loss and uncertainty.  For example, the loss of family, friends, job, money, status, health or indeed any change of routine.

7. The capacity to express sexuality within mutual satisfying and established relationships.

8. Perhaps the level of intelligence and achievement.  Intelligence is used her to denote an overall measure of skills gained.  It covers normal skills, the ability to conceptualise, handle words and figures, to find one’s way around the world, to judge the nature of social and emotional relationships and to respond appropriately.

9. Finally, we look for their levels of spontaneity, flexibility and the ability to look for options and adaptations in the functioning of life.

Shame: The Forgotten Emotion

Shame, more than any emotion, can be seen as the enemy within.  It is for many the forgotten emotion.  Indeed, in research for this blog, I was starkly reminded of the little that is written in the literature of the consequences of shame or even what shame is as an emotion.

Freud, for example, concentrated on the subject of guilt rather than shame.  Perhaps though the major reason for the ignoring of shame in this sense is that most often a person’s response to shame is to hide and withdraw, to retreat and remain isolated.  The last thing a shamed person wants to do is to open up and be seen by people and to feel exposed.  

“Shame is an internal, excruciating experience of an expected exposure.  It is a deep wound felt primarily from the inside.  It divides us from ourselves and others.”  (Erskine, 1993)

In TA terms, we can see shame as an “internal expression of an intrapsychic conflict between a reactive child ego state and an influencing parent ego state.”  (Erskine, 1993)

Shame is the consequence of a rupture in early relationships.  It is one of the most painful of emotions and for most people who feel shame, they want so desperately to “not been seen”, to many it is the very focus of attention that is so crippling for them in their everyday lives.  Indeed the moment attention is solely focused on them, they fight so desperately to withdraw and will do anything to not feel the feelings that are around by “being seen”.  The defences to the above may include freezing, trying to be perfect, intellectualising, smiling or creating another self to deal with the world.

The major script belief for dealing with shame is “something is wrong with me”.  This decision that something is wrong with their very being is made by the person early in their life in response to being traumatised by the “other” in the significant relationship.  It is the internalisation of the shame as a message that something is wrong with you, which is changed significantly by the shamed person/child to “something is wrong with me”.  This process usually begins early in childhood and it may take the shamed child numerous traumatic experiences before the “something is wrong with you” message becomes the “something is wrong with me” decision.  The parent in this process is facing a total responsibility for the rupture of the relationship from the child and will by definition set up a process where the child will be faced with great internal/external pressure to feel that there is something wrong with them.  The alternative voice or even feeling that it could be the parent that it wrong would be so overwhelming, especially as they were dependant on their early survival from the significant other.

This internal belief system, “something is wrong with me”, then becomes the basis of core of their early decisions and their script system.  It becomes the base from which the child then builds on in their development.  It is based on the myth to which this shamed child has bought into and become evasive throughout their life.  Indeed the myth becomes, to the person, as powerful as any existential decisions about themselves.  This is how they see and feel themselves.  This is what they are and how they exist.  They fundamentally believe that “something is wrong with me”.

The question then for any therapist/counsellor in dealing with a person who feels so ashamed and so fundamentally believes that the other is how we facilitate the person to realise that something is right with them, not wrong, and how we do this in a way that is not reinforcing the shame or replicating the early ruptured relationship. 

The answer lies in the relationship between the therapist and the client.  It is through this relationship that the person can tell their story.  It is through this relationship with the therapist that the person can maybe for the first time feel that they are validated for being themselves.  They are normal and there is nothing wrong with them and never has been.  It means the therapist attuning with the client, validating even the smallest hurts and anxieties, it means the therapist can somehow get themselves “into the skin of the client”.  Most of all it means that the therapist stays alongside the client in a respectful contact-orientated manner.

It may also mean that the therapist actively takes responsibility for any break in therapeutic relationship.  Most therapeutic relationship breaks occur when the therapist fails to attune to the client’s affective or non-verbal communication.  Thus it may be necessary for the therapist to take full responsibility for not understanding the client’s phenomenological experiences, for not validating or valuing the person in front of them.  The methodology then for therapy with the person who feels existentially evocably shamed is through contact, enquiry, attunement and involvement.  The four basic tenants of any relationship contract or therapy.  It is through the above with respectfulness that the antidote to shame will be found.

The importance of psychotherapists using permissions within the therapeutic relationships with clients...

This blog is about the importance of psychotherapists using permissions within the therapeutic relationships with clients.  It is vital that therapists think of using permissions for many reasons.  

Firstly, to actually take on the negative parent in a person’s psychological process.  

Secondly, to actually be able to voice what the client may not be able to actually be aware of, is vital for them, and thirdly, in the service of validation for the client’s very being.  

I often think of permissions as vital in the process of helping the client develop a robust sense of self and defeating or desensitising the negative voice they often carry around within their psychological structure.  

So firstly the permission to exist.  That’s a very important permission to explicitly say to the client as it gives the client the permission to allow themselves to take on board that they exist and they have a right to exist.  Secondly, the permission to experience one’s own sensations, to think one’s own thoughts and to feel one’s own feelings as opposed to what others may believe one should think or feel.  Thirdly, permission to be oneself as an individual of appropriate age and sex with potential for growth and development.  Fourthly, the permission to be emotionally close to others.  This again is very important in the sense of validating someone’s sense of self and challenging often the injunction that people carry around which is not to show feelings or not to be close to others.  So this is a very important permission.  Fifthly, permission to be aware of one’s own basic existential position.  In other words, that they’re ok and people are ok.  That people are born basically ok and that other people are born ok as well.  Permissions to change this existential permission.  So if they haven’t decided people are ok but actually perhaps come from another position that people aren’t ok or that they’re not ok then it’s important for them to realise they can actually change their fundamental view on life.  Seven, the permission to succeed in sex and in work.  That is to be able to validate one’s own sexuality and the sexualities of others and to “make it”.  Eighthly, permission to find life meaningful and this is important to encourage people to reflect on their own purpose in life, their own existence and that life can be meaningful to them.  Often clients think of life as particularly unmeaningful.

I haven’t put these permissions down in any linear order.  They’re ones that I find useful working with clients and I see I haven’t put permission to be joyful there which is also very important.  And finally, perhaps a permission which is most important to say is their permission to be themselves.  Their unique, special self which is so important to the validation and growth of their self-esteem.

Ok, in conclusion, these permissions I believe are vital.  They will help the person develop a good sense of robustness in life.  To be able to carry around these permissions are the basis of self-esteem and validation of the self.

The Difference Between Counselling and Psychotherapy.

The Difference Between Counselling and Psychotherapy.  

Ok, I decided to write this blog simply because a lot of people ask me what’s the difference between counselling and psychotherapy and in fact there’s not a right or wrong answer here.  The two major regulating bodies which is the United Kingdom Council for Psychotherapy and the British Association for Counselling and Psychotherapy have debated this for a long time.  So really this is more of my views, collections of other people’s views but really my views on the subject.  I mean, in the course of going for licensing for psychotherapist and counselling which we never actually got, there are six or seven years, the BACP did come out with at least one difference between psychotherapy and counselling and their different was this that the UKCP and the BACP agreed on was this, that in a counselling trainings there is one major difference between the psychotherapy training and counselling training and that is that counsellors are not trained to deal with or assess personality disorders, where psychotherapists are trained on how to work with personality disorders, people who are more disturbed and how to also assess them as well, whereas counsellors aren’t.  So that’s interesting but of course I think there’s many other differences.  

I’ve run the assessment referral system for the last sort of twelve years when they first introduced psychotherapy and people always ask me this question – what’s the difference between psychotherapy and counselling?  The only major sort of themes which come out, especially from the public is that they see counselling as much more short term, they see psychotherapy as longer.  They go to GPs for example, you probably only get six to eight sessions of counselling, whereas if you sign up for psychotherapy, usually privately of course, it can go on for one or two years, but of course you do have short-term psychotherapy as well.  I mean the other differences that’s come up is that counselling often is cheaper other than psychotherapy.  Psychotherapy can go from any prices from £40, £50, £60 an hour and above where counselling is less expensive than that.  So that’s two themes that have come out.  Another one is that people tend to think of psychotherapy as more scientific than counselling which is an interesting one.  I think that comes from Freud’s early psychoanalysis, the idea of the human personality being more mechanical or having a scientific basis to it.  In the theme or differences if you like of psychotherapy which comes out a lot and I think it’s more a myth than reality but anyway, that counselling is more in the here and now and psychotherapy is more to do with making connections from the past to the present.  Now on one level this is true but on another level we’ve seen the birth of therapeutic counselling in the UKCP and the BACP where we have a therapeutic part of the counselling procedure where many, many counsellors work in connection with the past to the present so I don’t think it’s as clear cut as saying that the counselling world deals with the present and the psychotherapy world deals with the past.  I think there’s far more overlaps here, far more emerging in present time and past time.  

It’s an interesting one.  I think it is the public’s major idea of how they see the difference between psychotherapy and counselling.  So there we are, we’ve got the fact it’s seen to be that counselling seems to be more cheaper, psychotherapy more expensive, the counselling is shorter in duration to psychotherapy, that psychotherapy is dealing with the past connections to the present and counselling is in short term and that sometimes, well, one theme that did come out of this is that the public see counselling as much more in general terms and that psychotherapy is more scientific.  Other differences seem to range, well they all seem to go on these themes really.  

Ok, so those are the major themes I see emerging over and over again.  

Importance of being emotionally available for your children

This is Stephanie Cook speaking and I wanted to talk about the importance of being emotionally available for your children.  More particularly because of the impact it has on brain development.  

When children are born they have, I suppose, a blank page in terms of emotional development and their brain is the area in which that is a bit like a computer.  It is programmed so if you don’t give your child the care and attention and the support for regulating their feelings and of course, that’s going the damage the neurones and the pathways in their brain.  So it’s really important that when children are very small that we pay attention to their emotional needs so that they can then learn how to self-regulate.  

So, for example, the human brain has got two parts to it.  It’s got the mammalian brain and the reptilian brain, and the reptilian brain is important because it helps us to, well it sends signals of alert when, for example, we are emotionally challenged or stressed in any way, and it sends signals to the amygdala to then action the hypothalamus to produce stress hormones, and what those stress hormones do is switch off all the other actions in the body and help us focus on the fight or flight reactions.  

Now of course, in a normal course of event, if a child is anxious what the mother will do, or the father or the other care givers in the family, will come and take care of them, calm them, and contain their feelings and help them manage their feelings, and so that then sends signals to the brain and it opens up the neurones and the pathways and they then develop, a  bit like a computer – a blueprint on how to manage their feelings.  If this doesn’t happen then of course the child doesn’t learn those abilities about managing their stress and self-regulation.  Now this has a huge impact, not just when they are small, but as they get older and when they become adults, it impacts them in terms of how they are able to manage themselves in the world and they’re not able to self-reflect or make emotional attachments and in some cases become aggressive and violent, and sometimes they become depressed, so it’s really important that we pay attention to our children and help them cope with their emotional sense of themselves.

For this blog I’m talking to Stephanie Cooke here and I’m just going to ask her a few questions.  So the title of this blog is How Do We Actually Self-Regulate our emotions as adults if we’ve actually not had that modelling from our early caretaker figures.  So how do we actually soothe ourselves in times of emotional stress?  So, that’s the first question I’ll ask Stephanie and she’s going to give us a few tips here on how we can as adults self-regulate our emotions if we haven’t had those messages from our processes, models as a child.  Ok, over to you Stephanie.

S: There’s a few things you can do to help support you while you are working therapeutically on learning how to self-regulate.  One of the things you can do is you can take a transitional object from your therapist which is something maybe out of the room that you work with in the therapy and you can remind yourself when you take it out of the therapy room, every time you can stressed, you can remind yourself of some of the things that you may have discussed with your therapist like for example, it’s ok to have your feelings, it’s ok for you to be distressed and get support while you are distressed.  The transitional object is a reminder really of the work you’re doing.  A bit like when a child carries around a favourite teddy bear or a blanket or a dummy, it’s just to remind you that there is a significant other around that can really take care of you.

So, it seems to me Steph that there’s good tips.  So can you just give us a few words for this blog on what’s the deficit then?  What didn’t happen for this person as a child in terms of modelling, of how to emotionally regulate?

S: Ok, well let’s talk about what happens normally between a mother and child.  When a child gets distressed, what the mother does is help that child to cope with that stress by validating it and validating their feelings.  So the mother will respond immediately to the baby or the young child, hold them, contain them, talk to them, stroke them, nurture them and help them to feel better, and while that’s happening that child will be releasing first of all stress hormones and as they are being soothed and contained, those stress hormones will turn into a different chemical which will then help relax them and help make them feel better.  So the most important thing for that child is for the mother to validate how they feel and to respond and it’s the response that’s really important.  Now, if that doesn’t happen and the mother doesn’t respond, what will happen is the child will continue to produce a stress hormone and get more and more anxious to the point where they’ll become despairing and extremely distressed, and in some cases what happens is that stress hormone will then become destructive to some of the neurones and pathways in the brain so what happens in that process is that they then become destructive so the child will actually not learn how to self-regulate themselves.

Right Stephanie, that’s a really good description of the deficits when we’re talking about emotional regulation.  Of course the good part of this while I listen to you and that’s really good tips by the way, is the modern research now is showing that we have plastic brains.  In other words there’s a level of plasticity in our brains and we can mould them and change them, so none of this can’t be repaired.  So thank you, I really like the tips for the blog and thank you again.