CC 14

UNIT 4
CRISIS INTERVENTION: COUNSELLING FOR SEXUAL ABUSE

DEFINITION AND MEANING

Sexual abuse is sexual contact that involves physical or psychological coercion or at least one
individual who cannot reasonably consent to the contact (e.g., a child). Such abuse includes
pedophilia, incest, and rape, and it concerns society much more than any other sexual problem. It is
somewhat ironic, then, that of these three forms of abuse, only pedophilia is included in DSM-5. This
partly reflects the seriousness with which the society views these offenses and its preference for
treating coercive sex offenders as criminals rather than as having a mental disorder (although
obviously many criminals also have mental disorders). (Butcher, Hooley and Mineka, 2014).

According to American Psychological Association (2018) Sexual abuse, also referred to as

Sexual abuse is unwanted sexual activity, with perpetrators using force, making threats or taking
advantage of victims not able to give consent. Most victims and perpetrators know each other.
Immediate reactions to sexual abuse include shock, fear or disbelief. Long-term symptoms include
anxiety, fear or post-traumatic stress disorder (APA, 2021, adapted from Encyclopaedia of
Psychology).

When force is immediate, of short duration, or infrequent, it is called sexual assault.

The term also covers any behavior by an adult or older adolescent towards a child to stimulate any
of the involved sexually. The use of a child, or other individuals younger than the age of consent, for
sexual stimulation is referred to as child sexual abuse or statutory rape.

Manifestations of Sexual Abuse

Sexual abuse happens when someone is forced or pressured into taking part in any type of sexual
activity. This includes being forced to have sex (rape), being sent sexual messages/images against
your will (sexting) or being touched in a sexual way without your permission (sexual assault).

This type of abuse can also involve being forced to have sex with someone in return for money
(sexual exploitation), being bullied in a sexual way (sexual harassment) or being forced to take part
in ritual abuse (female genital mutilation).

VICTIMS

Spouses

Spousal sexual abuse is a form of domestic violence. When the abuse involves threats of unwanted
sexual contact or forced sex by a woman's husband or ex-husband, it may constitute rape,
depending on the jurisdiction, and may also constitute an assault.

Children
Child sexual abuse is a form of child abuse in which a child is abused for the sexual gratification of an
adult or older adolescent. It includes direct sexual contact, the adult or otherwise older person
engaging indecent exposure (of the genitals, female nipples, etc.) to a child with intent to gratify
their own sexual desires or to intimidate or groom the child, asking or pressuring a child to engage in
sexual activities, displaying pornography to a child, or using a child to produce child pornography.

Sexual abuse by a family member is a form of incest, which can result in severe long-term
psychological trauma, especially in the case of parental incest.

People with Developmental Disabilities

People with developmental disabilities are often victims of sexual abuse. According to research,
people with disabilities are at a greater risk for victimization of sexual assault or sexual abuse
because of lack of understanding (Sobsey & Varnhagen, 1989).

People with Dementia

Elderly people, especially those with dementia, can be at risk of abuse. There were over 6,000
"safeguarding concerns and alerts" at UK care homes from 2013 to 2015. These included alleged
inappropriate touching and worse allegations. Offenders were most often other residents but staff
also offended. It is suspected some care homes may deliberately overlook these offenses.

Sometimes abuse victims are not believed because they are not seen as credible witnesses due to
their dementia. Perpetrators frequently target victims who they know are unlikely to be believed.
Spouses and partners sometimes continue to pursue sexual relations, without realising they no
longer have this right, because the person with dementia can no longer consent.

Poverty

People in poverty, including those from developing countries, are vulnerable to forced prostitution,
live streaming sexual abuse, and other forms of molestation. Victims who come from families in
poverty often have less connections, power, protection, and education about sex crimes.

Elders

Sex abuse is one of the most common forms of abuse in nursing homes. If a nursing home fails to do
proper background checks on an employee who subsequently abuses residents, the home can be
liable for negligence.

If nursing homes fail to supervise staff or train staff to recognise signs of abuse, the home can also
be liable for negligence. Sexual activity by care givers may be a crime. Victims may not report abuse
or cooperate with investigations due to associated stigma and/or reluctance to mention body parts.
Psychological Changes after abuse

Experiencing sexual violence can lead to a number of different emotions. There is no right or wrong
way to feel. The victim may experience some (or all) of the following:

• Numb - The shock and trauma of sexual abuse can make one feel numb to it. one may find
oneself feeling strangely calm, or simply unable to process what has happened.

• Guilty - Individual may be telling herself that it was her fault, even though it wasn’t.

• Angry - Feeling anger is common, one may feel anger at the person who did this to him/her,
or even at self.

• Ashamed - one may feel embarrassed and ashamed about what happened, even though it
was not one’s fault and totally out of one’s control.

• Depressed - One may lose his/her enjoyment of life, feeling like there’s nothing to look
forward to anymore.

• Anxious - Activities one used to do without a second thought may now make one feel
anxious, like going out alone.

Additionally, sexual abuse or violence can have a profound effect on a survivor’s attitude towards
sex. A person may find that s/he have become very conflicted after the event. It is normal for their
attitude towards sexual encounters to turn one of two ways:

• becoming hyper-sexual or

• suffering from sexual anorexia (avoidance)

It’s important to recognise that one’s attitude towards sex following abuse is not bad or immoral.
One may have a lot of inner hurt that is implicating your thoughts and behaviours towards sex. But
recovery and healing are possible, and one won’t feel this way forever.

Crisis Intervention Programs

Counselors should be familiar with the rape crisis intervention services in their communities so that
they make appropriate referrals when necessary. Many communities have established rape crisis
centers to serve as first responders to sexual violence in their communities. Most of these agencies
provide crisis intervention through medical and legal advocacy. They provide volunteer advocates to
accompany survivors to hospitals and police departments and to guide them through the process of
medical forensic evidence collection and legal prosecution. The advocate not only facilitates the
delivery of these services but also helps to protect the survivor from secondary victimization by
promoting positive interactions with other professionals (Campbell, 2006). To assist in the medical
aspects of rape crisis intervention, many communities have developed Sexual Assault Nurse
Examiner (SANE) programs that hire nurses who are specifically trained to provide crisis/medical
intervention, collect forensic evidence, provide appropriate postrape medical care, and coordinate
services among multiple service providers (Campbell, Patterson, & Lichty, 2005).

Rape crisis centers also provide survivors with information about available services and resources,
promote social support, provide psychoeducation regarding common reactions to sexual assault,
and offer options to facilitate a survivor’s ability to make informed decisions during this diffi cult
time in his or her life (Ullman & Townsend, 2008). Most rape crisis centers also offer supportive
counseling and 24-hour hotlines for survivors and their support systems.

Counseling Treatment Model

When counselors work with sexual trauma survivors, they first should work to develop a trusting
therapeutic alliance, as survivors may have great reluctance to discuss their memories of the trauma
and may have had negative experiences with other service providers. Counselors should
demonstrate empathy and positive regard for clients as they carefully assess client concerns through
the multisystemic lens. This type of assessment is imperative in developing a treatment approach
that is tailored to the client’s specific needs.

To provide trauma-informed counseling services, counselors can integrate information regarding the
client’s context while following research-supported treatment guidelines.

The treatment approaches outlined in the following text are drawn from expert consensus
guidelines for the treatment of PTSD (Foa, Davidson, & Frances, 1999; Foa, Keane, & Friedman,
2000) and are adapted specifi cally for rape-related trauma. The recommended treatment
components address specifi c PTSD symptoms that occur following sexual trauma: (a)
psychoeducation about commonly experienced PTSD symptoms, (b) exposure therapy (ET) to
facilitate the client’s ability to process memories related to the event, (c) cognitive restructuring (CR)
to challenge the client’s maladaptive beliefs about his or her role in the event, and (d) anxiety
management techniques to enhance positive coping skills. For a complete discussion of these
components, see Choate (2008), Foa et al. (1999), and Resick and Schnicke (1993).

Psychoeducation

Survivors of sexual trauma benefi t from receiving information regarding commonly

experienced reactions to sexual assault (e.g., guilt, anger, shame, powerlessness, helplessness,

fear) and the symptoms of PTSD as described previously (Marotta, 2000).

Many survivors express that they feel relief when they realize they are not “crazy”

but are rather experiencing an expected reaction to a highly traumatic event (Rauch,

Hembree, & Foa, 2001). The counselor should be prepared to provide information and

resources about medical and legal decisions and assist the survivor in accessing the

services of the local rape crisis center, as appropriate.

Exposure Therapy

The two treatment modalities for sexual trauma with the most research support are ET and cognitive
behavioral therapy (CBT) with CR (Russell & Davis, 2007).

The goal of ET is to assist a survivor in working through painful memories, situations, thoughts, and
emotions associated with the traumatic event and which currently evoke anxiety and fear. As noted
previously, many survivors of sexual trauma engage in avoidant coping strategies in order to avoid
this intense anxiety and fear (Fortier et al., 2009), and it is understandable that they will be resistant
to this strategy when it is presented to them in counseling. To encourage clients to undertake this
difficult work, counselors should express empathy and acknowledge a survivor’s fear, spend time
educating the client about the rationale for this treatment strategy, and convey positive
expectations for recovery (Draucker, 1999). As suggested by Foa, Rothbaum, and Steketee (1993)
and as adapted by Choate (2008, p. 177), counselors can explain the use of ET to clients in the
following way:

1. Memories, people, places, and activities now associated with the rape make you highly anxious,
so you avoid them.

2. Each time you avoid them, you do not finish the process of digesting the painful experience, and
so it returns in the form of nightmares, flashbacks, and intrusive thoughts.

3. You can begin to digest the experience by gradually exposing yourself to the rape in your
imagination and by holding the memory without pushing it away.

4. You will also practice facing those activities, places, and situations that currently evoke fear.

5. Eventually, you will be able to think about the rape and resume your normal activities without
experiencing intense fear. When the client is ready to begin the process, the counselor can use
imaginal exposure to assist the client in repeatedly recounting memories associated with the sexual
trauma until the memories no longer cause intense anxiety and fear (Foa et al., 1999). Clients are
asked to close their eyes, to imagine the traumatic event in vivid detail, and to describe it as if it
were happening in the present. Writing about the event in a journal also may be helpful for clients as
they practice describing their memories outside of sessions (Harris, 1998). This is an extremely
difficult phase of treatment for clients as they face the thoughts, feelings, and images associated
with the event that they have been attempting to avoid out of fear. Counselors should acknowledge
this difficulty and encourage clients in their willingness to process the event gradually in order to
cope with their fears.

ET also involves in vivo exposure , a process through which clients are asked to focus on activities
and situations associated with the event that they currently avoid because it evokes intense fear and
disrupts daily functioning. The client hierarchically lists all avoided situations and activities, ranking
them from least to most distressing. It should be noted that the counselor should review this list to
ensure that these situations or activities are actually safe and that it includes only those things that
are interfering with the client’s ability to engage in his or her daily routines. Starting with the activity
or situation that is least distressing, the client remains in this particular environment for a minimum
of 30 minutes.

This time is recommended because it is long enough for the client to experience fear, to evaluate the
actual level of danger present in the situation, and to allow the fear and anxiety to decrease. Anxiety
management techniques can be used during this time. Over the course of counseling, the client can
progress through the hierarchy until he or she is able to resume daily routines and functioning.

Cognitive Restructuring

CR is effective in reducing symptoms associated with sexual trauma (Foa et al., 1993; Resick &
Schnicke, 1993; Russell & Davis, 2007). In this phase, clients learn to identify the automatic thoughts
or beliefs that they experience during negative emotional states related to the sexual trauma. The
counselor’s ability to understand the client’s broader context can assist the client in fully identifying
and exploring thoughts and beliefs related to the traumatic event. As clients identify these thoughts
and beliefs, they learn about typical cognitive distortions related to sexual trauma, learn to evaluate
distortions, challenge them, and eventually replace them with more rational or beneficial thoughts
(McDonagh et al., 2005; Meadows & Foa, 1998). One specific form of CBT with CR that is designed
specifically for rape-related trauma is cognitive processing therapy (CPT; Resick & Schnicke, 1993). In
CPT, survivors learn to identify and challenge “stuck points” in five specific areas: self-blame and
guilt, power and control, self-esteem, trust, and intimacy. These are described briefly in the
following text.

Self-Blame and Guilt.

As described throughout this chapter, self-blame is perpetuated by cultural beliefs and by negative
reactions from others in the survivor’s life. Individuals who incorporate negative social reactions into
their overall view of themselves tend to have the highest levels of PTSD symptoms (Regehr, Marziali,
& Jansen, 1999; Ullman, Filipas, Townsend, & Starzynski, 2006). It is therefore important for
counselors to help their clients distinguish between attributions of blame assigned to their character
(e.g., “I am a bad person and deserved to be raped”) versus assigning blame to some aspect of their
behavior (e.g., “I made a decision that day that I might not make now”). Guilt often is related to self-
blame, in that the survivor may perceive that he or she is responsible for the violence or did not do
enough to fight back or to prevent the crime. The counsellor can assist the client in examining self-
blaming and guilt-related beliefs and can help the client begin to replace these thoughts with more
logical and growth-enhancing self-statements (e.g., “I did not do everything right in this situation,
but the rapist is fully responsible for this crime. I will now do everything I can to reclaim the power
taken away from me by this crime”; Choate, 2008).

Power and Control.

During an act of sexual violence, an individual is stripped of his or her power, and often survivors
continue to feel powerless and out of control long after the trauma has ended. Counselors can assist
the client in focusing on restoring his or her sense of personal power, particularly regarding decisions
made in the present. As part of regaining power and control, counselors should encourage clients to
take an active role in the counseling process, providing them with as many choices as possible and
allowing for flexibility in the timing and pacing of sessions.

Self-Esteem.

In their CPT treatment manual, Resick and Schnicke (1993) recommend helping clients to focus on
the effect that the sexual trauma has had on their views of themselves. Clients’ answers to these
questions can help to uncover automatic negative thoughts such as “I am unlovable” or “I am
damaged goods.” Through CR, clients can learn to separate the events and their reactions from their
views of themselves as

individuals (e.g., “Being a survivor of sexual trauma is a part of who I am, but it does not define me. I
have strengths and a sense of self that this trauma did not disrupt”).

As a part of this process, the survivor can gradually learn to view the sexual violence as a traumatic
but growth-enhancing event. It is helpful for clients to know that most individuals report some type
of growth after a traumatic event, including greater selfawareness, strength, maturity, a more
flexible worldview, increased empathy, greater sensitivity to the suffering of others, and changes in
relationships, spirituality, life philosophy, or life priorities (Frazier & Burnett, 1994; Frazier et al.,
2001; Koss & Kilpatrick, 2001; Williams & Sommer, 1994).

Trust and Intimacy.

Because sexual violence often is committed by someone the survivor knows and trusts, a client’s
capacity for intimacy and ability to trust may be disrupted.
If a survivor questions his or her judgment in selecting safe relationships, engages in self-blame, and
receives victim-blaming reactions, he or she can develop particular problems in trusting both self
and others. To change these stuck points, clients can explore beliefs they have developed related to
relationships and about the world in general (e.g., “People are bad and can’t be trusted”; “The world
is unsafe and unfair”; Frazier et al., 2001). They can then change those beliefs that are impediments
to their recovery, evaluate current relationships and their interactions with others who can provide
support, and fully explore the need for positive connections with others as part of the recovery
process.

Anxiety Management

Because one of the primary symptoms following a rape trauma is anxiety, anxiety management
techniques are suggested both to prevent and to reduce these symptoms. Meadows and Foa (1998)
suggest teaching clients coping skills to reduce anxiety-related symptoms such as hypervigilance,
hyperarousal, sleep disturbances/nightmares, and difficulty in concentration. These coping
strategies include progressive muscle relaxation training, controlled breathing exercises, role
playing, covert modeling, positive thinking and self-talk, assertiveness training skills, guided self-
imagery, and thought stopping. Clients can become empowered as they learn to employ these and
other anxiety management strategies that promote recovery from sexual trauma.

Reference:

Butcher, J.N., Hooley, J.M and Mineka, S. (2014) Abnormal Psychology (16th ed), Pearson.

https://www.apa.org/topics/sexual-assault-harassment, retrieved on 6/5/21

Levers, Lisa Lopez. (2012) Ed. Trauma counseling : theories and interventions. Springer Publications

PREPARED BY DR CHANDANA
ADITYA

ASST. PROF, PSY, WCC