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Chapter Three: The Views of Survivors
Through many years of talking and carrying out research with survivors of childhood sexual abuse, we have found there is a strong consensus about the kinds of people and services they value as most helpful.
These are a few of the major points survivors have made:
Many survivors, for reasons already discussed, find it very difficult to raise, or discuss, their own history of abuse. This does not mean that survivors do not want to be asked, or to be offered an encouraging atmosphere for disclosure. Indeed, many have been sending out signals since their childhood in the sometimes desperate hope that these will be picked up and acted on. If professionals keep waiting for clients "to be ready", they may wait forever.
Most of the survivors we have met have been much more frustrated and upset about not having abuse issues recognised or dealt with (often for decades), than with having the issues raised. The failure of many services to accurately perceive their distress was a huge problem for most survivors in the Beyond Trauma study.
"It wouldn't have mattered if I'd been in a coal cellar (instead of the psychiatric ward), so long as there was someone to help me, and to listen. If you had a trained counsellor or psychiatrist who was prepared to listen, instead of asking all the time, what are you thinking? Someone without a time limit on them; someone who's not going to patronise you."
In fact, it is so rare to meet an adult survivor who expresses concern about being asked sympathetically and sensitively about a possible history of abuse, that it's difficult to figure out where this preconception comes from. In some countries, such as the USA, questions about childhood trauma are included much more often by medical or psychiatric professionals in questionnaires, and inventories on physical or mental health. No major problems of acceptability appear to have been uncovered through this practice. Some professionals in this country also routinely explore for possible abuse issues. For instance, more than 80 patients within the space of about two years revealed an abuse history to former Scottish GP Dr Willie Angus, who has written about the issue for GPs in the British Medical Journal4 and about the symptom relief which occurred for many patients. He told health in mind:
"I was never criticised by patients for asking them if they had suffered from abuse, or were sexually abused as children. I see no reason why, in suitable circumstances, the question cannot be sympathetically addressed to anyone … those to whom it did not apply seemed undisturbed and answered in the negative. Most survivors were considerably relieved when the question was asked as they had, in many cases, tried to bring up the subject but felt unable to do so in case they were disbelieved or rejected."
Ways of asking: Some survivors appreciate being asked directly, others less boldly. If staff and volunteers don't feel comfortable asking the question outright, a range of diplomatic approaches and styles for building the issue into assessment procedures is possible, especially within broader questions about problems in childhood. Projects can also consult each other on what wording they have found helpful.
For instance, doctors at one Edinburgh practice where many survivors had come forward explained: "We might say, 'Depression is often related to stresses in a person's life. There might be current things, or things that happened in the past, that are still causing you pain…do you think there could be problems from your childhood?' Or we might say, 'Has anyone done anything to you that you wish they hadn't?' or, 'Was anyone horrible to you as a child?'."
A male survivor recalled: "I couldn't bring myself to say at that time. Well, after a while my CPN (community psychiatric nurse) just handed me a leaflet (for abuse survivors' project he now regularly attends) and said, matter of factly, 'I wonder if that might be any use to you?' And just left me with it so as not to embarrass me…"
One female survivor recalled: "I still say that [a fellow survivor] saved my life. We had known each other from way back. I was sitting drinking as usual and she arrives and says 'Hi, how you doin?', and then I remember her saying 'I was abused when I was a bairn. 'And I said,' So was I!' And she just let me go on and talk about it for hours. And that enabled me to tell my keyworker…"
- Please don't assume we're too vulnerable!
There is nothing worse for survivors than to be treated by staff in ways that reinforce their previous experiences of rejection. Yet survivors report that staff frequently fall into this trap, leading to a retraumatisation for them as they struggle with issues of blame, responsibility and power. The very fact they are survivors is testament to their resourcefulness and resilience in the face of extreme events that have happened to them.
Despite what may be the best of intentions of service providers in assessing clients for different therapeutic approaches, it can be very difficult for survivors to be told they are not suitable or that the treatment is not appropriate.
"I sat for two hours answering questions … at the end of it he said, 'I don't think you're suitable.' I said, 'I beg your pardon?' He said, 'I don't think you're suitable for psychotherapy … don't you think it would upset you too much?' I just thought, 'Rejected because I'd be upset? That's why I'm here, to speak to someone because I'm f***ing upset!' "
"Well they put me out. They told me I wasn't right for them and that I wasn't to come there. I remember it (the assessment) only went on for about 15 minutes and it was like, cheerio! I had to circle things and I think they thought I wasn't right for them!"
- Survivors value all kinds of time….
Many staff believe that you have to devote huge amounts of time to listening or responding to survivors, and that because their service can't provide this time, they feel it's better not to start. One problem is that every service a survivor passes through may take this view, so that they never actually receive the attention they need! Survivors do not themselves support this view: they value many opportunities to talk in different situations and settings, and all of these can be helpful.
Do not make assumptions: consult with survivors. While some do need and welcome long-term work many do not, or do not require it at this moment. Some will only want to tell their story once, and that is enough.
One exasperated psychiatric patient explained, after endlessly being asked unimportant details about her history but never about her abuse history:
"I'm a survivor. I want acknowledgement, receptivity and understanding. I just want someone to sit over there and listen to me …I need my story to be witnessed, and that's the validation I'm looking for."
What survivors do value are open-ended services, which they can dip into according to need (or repeat, in the case of a set programme). They can find it very frustrating if the few services available only offer six or ten sessions, expecting survivors to feel better in that time! Just as the effects of trauma are unpredictable, so are the times when people need help: " A drop-in service, or services you can keep returning to if you want, without a cut-off point. It's important just to know somebody's there: it doesn't mean you have to use them".
Nor should small amounts of time ever be devalued. Survivors repeatedly recall staff, volunteers, friends and family who were catalysts to changing their lives through brief interventions - perceiving the problem, taking a few minutes to listen or talk, suggesting something helpful, or being flexible enough to offer help at a vital moment. None of these helpful actions were, to use the jargon, 'rocket science'.
For example:
- A night nurse who talked to one very distressed pregnant survivor and gave her the courage to stop drinking in order to keep her baby.
- A night nurse who sat with a severe self-harmer, and explained that all the other staff were being horrible to her because they couldn't cope with the self-harm.
- A surgeon who spent 40 minutes before an operation reassuring a survivor whose experiences caused terror of medical procedures, and a physiotherapist who sat with her during treatment on a machine, to prevent her from dissociating and 'freaking out'; She would sit with me and talk about anything to keep my mind back on planet Earth."
- A fellow survivor who sensed her friend's life was at a dangerous point, and took her to her house where she confessed her own history of abuse. That led the friend to admit abuse for the first time and to phone her hospital counsellor. This nurse, sensing the importance of the moment, let her come and talk immediately, even though the client had been drinking heavily.
- A GP, puzzled by an old woman's conviction that she had a sexually transmitted disease, thinking to ask: " 'Was anyone horrible to you as a child?' She said, 'Yes, my father and brother', and it all came out. She felt she had wasted her whole life."
- We're not looking for great experts, we want a human being…
Many staff and volunteers feel huge inadequacy about working with sexual abuse and believe they need higher qualifications and lengthy training. But that belief is not supported by research, or by discussion with survivors themselves. Appropriate and focused training is important, but there are other important factors as well. In the Beyond Trauma study there was so much consensus about characteristics of the most helpful workers (see Summary, below) that we were able to draw up a pen picture, as well as interview some of the people they named. Helpful workers came from all professions and degrees of status, or qualification. They were skilful, "low-tech", imaginative and client-centred, but they also used simple, human ways of communicating and were modest and genuinely committed. Many of the typical qualities come through in this quote from one nurse who was named by survivors:
"I've not done special training, I've just been a nurse and worked with people. I've done the reading myself - I just feel it's my job to contain people's emotions, to show that I'm not horrified. I'm not going to rush from the room to get a tablet. I believe I should let them talk - I don't have a (formal) structure as such, apart from that. It's a two-way thing, asking people if they want to talk about that ( e.g. something that came up yesterday) or leave it for now….
It can be really dramatic sometimes. I once saw a woman almost go back to when she was a child in the bedroom, the terror, breathing etc I wasn't sure what to do, so I just talked her down. I acknowledged what was happening … I held her hand and talked to her."
Survivors do not mind if helpers confess that they don't know something, or still have things to learn. Nor do they mind if a support person shows some sympathetic emotion. Survivors don't want to work with a cold and impassive listener nor, in contrast, do they want to work with someone who breaks down and is unable to continue. As one survivor who had disappointing experiences with many professionals recalled:
"My CPN (community psychiatric nurse) was the first person to show emotion when I told her about some of those terrible things. I was touched by this. A few days later she confessed to me, 'I feel I'm not experienced enough to be able to see you and talk to you. The last time (we spoke) you were on my mind for four days, even at home, and I saw my superior about it and she would like me to stay on with you and I would like (that). But I just want you to know I don't have the experience…' Well I appreciated that … it ended up that I was getting the names of books on sexual abuse over the internet for her to read!"
Summary:
Whom do survivors find most helpful?
In the Beyond Trauma research, professional status, qualifications, and theoretical approaches emerged as much less important for survivors than the qualities listed below. The most helpful person:
- Is secure about boundaries, but relates with warmth and kindness
- Is informed and aware about CSA, or keen to learn
- Has examined his/her own issues around CSA
- Works non-hierarchically, consults clients, reaches joint decisions
- Is client-centred, flexible, imaginative
- Neither hides behind confidentiality, nor breaks it insensitively
- Has courage to stay with clients through distressing details or behaviour
- Is prepared to work over a period of time, though brief contacts can sometimes be the catalyst to life changes.
Survivors also valued being offered a choice of gender in the worker.
It is interesting that there were many similarities between these recent findings and the findings of other published research on therapist-client variables, such as that summarised by Peter Dale in his book Adults Abused as Children 5. Positive outcomes for clients were consistently more closely associated with the personal characteristics of therapists, than with therapeutic orientation or techniques. There were other similarities in the characteristics perceived as being most helpful by clients:
- Personal warmth and likeability
- A non-judgmental attitude
- Being empathetic, accepting, objective, patient and understanding
- Demonstrating genuine interest in the client.
The next chapter suggests ways in which staff and volunteers can put some of these points into practice (and avoid some pitfalls) when talking and working with survivors.
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