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Balancing the Power Dynamic in the Therapeutic Relationship

Section 12
How to Interven
e - Assessing Trustworthiness
to Develop a Treatment Strategy

Question 12 | Test | Table of Contents

Read content below or listen to audio.

Now let's look at the healing experience, first for Mary, then for a client I'll call Lynn. Let's see how the healing experiences of Mary differ from those of Lynn. When asked to describe "healing experiences," here is a summary of what Mary stated through several sessions:

♦ 6 Steps of Mary's Healing Experience
1. Talking
to a health care professional who believed me and wanted to help in the best way for my process of healing.
2. My own personal ways of healing myself which were: being in nature; telling myself healing thoughts; doing some of the things I used to love doing and was good at; staying in a relationship with a loving man, even though many difficulties presented themselves.
3. Telling my friends and family about it. Having one close friend with whom I could share details of the abuse and the intense feelings about the mental health professional. My friend believed me even when I found it so unbelievable.
4. Knowing that my life is good.
5. Looking at the work relationships that intimidate me and (seeing) how this was related to the abuse, and getting help to work through it and do some "damage control."
6. Feeling like I'm moving on in my life.

♦ 7 Steps of Lynn's Healing Experience
In the literature, Lynn, a social worker who was sexually abused by her therapist, wrote that her healing experiences included:
1. Leaving her subsequent therapist when she realized that he did not believe that she had been abused.
2. Finding another therapist, who believed her and who arranged for some very practical cognitive and biofeedback treatment for Lynn's severe insomnia.
3. Moving to a new community.
4. Making an ethics complaint to the abusive therapist's professional organization.
5. Getting involved herself in a committee dealing with ethics complaints.
6. Addressing conferences about sexual abuse by mental health professionals and teaching about the sexual boundary power imbalance.
7. Receiving support from colleagues.

5 Therapy Strategies I use with Victims of Sexual Abuse
Here is the therapy I use with Victims of Sexual Abuse. It is hoped the listener can broaden out these concepts to apply to clients with which they deal that suffer from abuse. Victims of abuse who have sought me out or have been referred to me have already learned of my therapy experience in this area. This reduces, but certainly does not eliminate, the anxiety and distrust that victims feel about starting therapy with another mental health professional. Some abuse victims are so anxious at first, so scattered and fragmented in their presentation, that it is hard to get a clear idea of their concerns.

♦ Strategy 1: Helping Victims Assess Trustworthiness
Their fragmentation often comes from an inability to trust. As you work with abused clients, you might recall a specific client at this time. Think back to their issues regarding trust. The steps involved in your client assessing your trustworthiness may be as follows.

Awareness of your client's process of assessing trustworthiness may assist you in developing treatment strategies.
a. Gathering information(include your "sixth sense" or "gut reaction" as references). A question the client might ask herself is: Is there someone whose opinion I respect with whom I can check my perceptions and who can help me sort out the information I do have about this person?
b. Forming an opinion (hypotheses, guesses) about that person. Questions the client might ask herself are: Can I devise a test whether this person is caring and trustworthy? Is there some small test I can take towards trusting this person that will not be too costly to me, to help me judge this person's trustworthiness?
c. Testing that opinion or watching to see whether your opinion matches the person's behavior in real life. Am I over-generalizing from my trauma experience to the present in any of my relationships?
d. Revising your hypotheses or guesses as a result of the new information; questions the client might ask herself are: What did I learn about him or her? If this person disappointed you, does this mean that he/she is not to be trusted at all, or that there are additional areas where this person isn't to be trusted? If so, what are these areas?
e. Repeating the process as necessary. As you know, "gaining perspective" refers to individuals' expanding the frames by which they judge events, themselves, and others. The expanded frame of reference facilitates seeing an event in a broader vista. By applying a calibrated measurement, individuals can obtain a more relative concept of magnitude, seriousness, and duration. In contrast, people who have lost perspective think in absolute terms, as though the present instance is of utmost importance and will go on forever.

♦ Strategy 2: Creating a Safe Environment
At first I concentrate on creating a safe environment and making sure that victims know that there are firm boundaries. Some victims, whose abuse happened in a private office, after the secretary left, say they feel very reassured by coming to a clinic setting where there are always other people about.

♦ Strategy 3: Hearing the Life Story
In the early sessions, I ask clients to give me as much as they can of their life story, including family background, and I assess symptoms of PTSD, Post Traumatic Stress Disorder, depression, or any other problems. Sometimes referral for a medication evaluation is useful, particularly in this first phase of therapy, for instance, if the client is very depressed. I feel giving information about PTSD is important. I always make a point to emphasize that therapy is a collaborative endeavor, that clients are the best experts regarding themselves, and that my role is more as a catalyst than as a director.

For clients that have cognitive dysfunction due to the trauma, some clarifying direct questions to get an accurate picture are usually needed. However, for the survivor, who has been abused by a therapist the usual questions like, "What exactly happened? When did it happen? Tell me everything that happened?" and so on, are all postponed until trust is established and the flow of information with the client is open.

♦ Strategy 4: Dealing with PTSD
As you know, post traumatic stress disorder is a normal reaction to an abnormal amount of stress. I feel it is important for the client to know that given enough stress, anyone can get PTSD. I often give the following example to my clients. Perhaps you might evaluate my method of explaining PTSD as it compares to the method you use to explain PTSD to your clients.

"During the Second World War, some soldiers with exemplary records of mental health and family stability developed PTSD after prolonged combat exposure. It was concluded that 200 to 240 days in combat would break even the strongest soldier. Many studies showed that the best protection against the development of PTSD in wartime was the presence of support from close buddies. However, this kind of support is often absent for the child or adult who is sexually abused."

Is this example of PTSD a tool you might gain from this home study course to use with your next PTSD client or patient?

As you know, the person with PTSD often alternates between an intrusive phase of re-experiencing the trauma and a phase of numbing and avoidance, when the person tries to bury the memories. A person with "delayed onset" PTSD may be symptom-free for months or years. Some see this as a very prolonged phase of numbing and avoidance. The person is propelled out of the symptom-free phase and into the intrusive phase by life changes or stresses, or by "triggers" or reminders of the original trauma.

Although use of the diagnosis has been criticized and seen as a way to pathologize the client and medicalize a normal response to a traumatic event, I've found in my practice that survivors welcome being told that such an entity as PTSD exists. The client finds it comforting to know that their frightening perceptions, and unpredictable emotions, are totally normal in view of the disastrous and intrusive nature of the ordeal they have suffered.

Mary experienced at least three episodes of delayed-onset PTSD. One occurred when she first started therapy with a therapist immediately following the abusive incident, and the second was when she was remembering the sexual abuse of her father. She continued to have some symptoms of PTSD, on and off. She was often tense and irritable, lost weight, had nightmares, and suffered terrible insomnia, often staying awake until 3 or 4 am. The third episode came much later, and was precipitated by increasing stress at work.

♦ Strategy 5: Supporting Feelings of Betrayal and Anger
As abuse survivors tell their story, I have found, like you probably have found, it is key to show I understand, accept, and support their feelings of betrayal and anger. The next phase is they begin to grieve for what has been lost as a result of their abuse and its after-effects. In Mary's case the abusive encounter at first hindered and then terminated the therapy she needed when she first went to a mental health professional. Mary felt she lost touch with the person she was before the abuse started.

At this stage, Mary was consumed with anger and wanting revenge. Some abuse victims decide to make a report to the police or a licensing authority or to embark on a civil suit. Because of the re-traumatizing nature of many survivors' experiences with these systems, I help them to face realistically the pros and cons, and if possible and appropriate, put them in touch with a survivor who is knowledgeable about the legal system.

In addition to recalling the abuse and grieving, clients need to understand how the abusive experience is affecting their current behavior, attitudes, feelings, and relationships. Previous issues, problems, and family difficulties that occurred before the abuse may need to be addressed. Remembering and mourning alone are not enough to repair the damage that many have sustained.

What is a key in working with a client who has been abused by a therapist? To select and enter your answer go to Test.

Section 13
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