CHAPTER 1
What Do I Say When a Client Discloses?
Sara, 22, was driving to visit her sister in another town. Stopped at a red light, three young men jumped in her car, put a gun to her head, directing her to drive to a deserted road where all three raped her. Injured and in shock, she managed to get herself to a hospital where she received help. Ten years later, however, she is the veteran of numerous failed relationships and has been fired from two jobs. When she sought therapy, the therapist suggested she join Alcoholics Anonymous to deal with her drinking problem. She says she has, before she considers "a more permanent solution" but is still plagued with flashbacks, panic attacks and hyper-vigilance.
Lorna is a petite 57 year old with the slightest trace of a Southern accent. When she talks about how her uncle raped her at the age of five, and continued to do so until she was eight, her eyes still fill with tears. She recalls that when she told her mother about the terror she felt when her uncle was around, her mother slapped her. Married to an abusive man for forty years now, she has been in and out of therapy for years, but her therapists told her the abuse happened so long ago, "it wasn't relevant" to her problems of depression and over-eating.
To anyone who knows him, Geoff appears to be the picture of calm and success. A school principal who is much in demand as a motivational speaker for adolescents, few know that his sexual abuse at the age of 8 by a family friend, and molestation by his priest at 14, has left him with a lifetime of nightmares, suicide attempts, and self-medication with alcohol. Too ashamed of the many doubts regarding his sexuality and depression to disclose his childhood abuses to the medical professionals who treated him over the years, he finally called a suicide hotline in tears. The mental health professional who responded suggested he see a psychiatrist for anxiety medication.
According to the united States Department of Justice:
• One out of four girls and one out of six boys are sexually assaulted by the time they are 18 years old and 30% of child victims are between the ages of 4 and 7;
• One in four college women have been assaulted or suffered an attempted assault;
• 86% of women, 93% of teens, and 97% of people with disabilities who were assaulted knew their attackers;
• One in five children are solicited sexually on the Internet;
• An estimated 39 million survivors of childhood sexual abuse exist in America today;
• Arrests are made in only 37% of cases and only 2.5% of rapists are convicted.
But this problem is not restricted to the united States or even war-torn Third World countries where women and children are routinely raped by invaders. According to the united Nation's Secretary-General's 2006 In-Depth Study on Violence Against Women, it is estimated that one out of five women will become victims of sexual assault during her lifetime – worldwide – including such "civilized" countries as Great Britain, Switzerland, and Australia.
Sexual assault and abuse is a social epidemic, labeled "the" most underreported crime by the united States Department of Justice, and is the deep, dark, dirty secret that is often at the root of substance abuse, depression, and suicide attempts.
It is also such a frightening topic for therapists that often, when a client discloses a sexual assault to his or her counselor, said counselor may unintentionally confound the problem by panicking, minimizing the psychological fallout from the abuse, and choosing to treat the symptoms – the substance abuse, depression, mood swings, hyper-vigilance, trust issues, and relationship problems – rather than the assault itself.
Why? Because even well-meaning and experienced counselors are misinformed and reluctant to delve into an area where they have little or no training. And as human beings, they — like all of us — are also products of their own cultures, religions, families of origin and social upbringing.
First – an important definition: rape is the social term; sexual assault is the legal term. From the 1920s until 2011, The FBI's Uniform Crime Report (UCR) defined rape as "carnal knowledge of a female forcibly and against her will." This definition covered only penetration of a woman's vagina by a penis, and excluded other forms of sexual violence.
In January 2012, revisions to the UCR's definition was broadened to expand the type of victims and cover multiple forms of sexual violence. The new definition of sexual assault is "penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim." (FBI, 2012).
In addition, most states have their own statutes governing the definition of sexual assault that might include the following language: Sexual Assault is any vaginal, oral or anal sex without the victim's consent, or with a victim who is unable to give consent (i.e., a victim under the age of 16, mentally impaired, or whose mental faculties is impaired by drugs or alcohol).
Despite a popular culture that flaunts graphic sexual situations (television and the media) and continually minimizes sexual assault through jokes and innuendo ("Get her drunk; maybe you'll get lucky!" – clearly satisfying the definition of sexual assault in that she may be incapacitated and unable to give consent), sexual assault is not an easy or polite subject about which to talk when the talk is serious. In fact, it is downright frightening.
As early as the 1970s, Susan Brownmiller was writing about the devastating effects for women of the widespread and 'insidious' fear of rape, and a study conducted in Queensland, Australia in 1992 on 412 subjects concluded that a fear of rape/sexual assault could be termed a "universal condition." So one would naturally think that, like most other fears and emotional conditions, mental health professionals today would be prepared to not only identify the signs of post sexual assault conditions but be able to implement relevant interventions. unfortunately, this is not so. In our fifteen years of experience in performing intake evaluations of sexual assault survivors, we have found that approximately 75 percent of those who had previously disclosed to other mental health professionals regarding their victimization, were told a variation of one of the following:
• "That (childhood incest) happened so long ago, I think we should concentrate on your depression and trust issues instead;"
• "I can see where that could have been a problem, but I think the more pressing issue is your drinking and how it is harming your marriage;" (said to a male survivor)
• "That must have been terrible for you, but you were brought here to deal with your substance abuse, we'll talk about your rape if we have time."
In each of these cases, the therapist minimized the client's trauma and sexual assault, while focusing on the more obvious mental health condition that is less threatening to address. In doing so, the therapist unwittingly re-victimized the client.
The link between sexual assault and the abuse of substances, and sexual assault and other mental health problems such as depression has been an ongoing source of study over the last twenty years by the World Health organization and for researchers like Dean Kilpatrick of the National Violence Against Women Prevention research Center at the Medical university of South Carolina. Among the statistics shared are:
• Almost one-third (31%) of all rape survivors developed Post Traumatic Stress Disorder (PTSD) sometime during their lifetime and more than 11% still fight it;
• Rape survivors were thirteen times more likely than non-victims of crime to have attempted suicide;
• Rape survivors are twenty-six times more likely to have two or more serious drug abuse problems than non-victims;
• Rape survivors are five times more likely to have abused prescription drugs, six times more likely to have used cocaine and ten times more likely to have used "hard drugs" other than cocaine then non-victims.
It becomes obvious that survivors of sexual abuse and assault are likely to use substances in order to numb out from the flashbacks, anxiety, and other symptoms of rape Trauma Syndrome (See Chapter 3) and this may actually be what gets them through the door of a therapist's office. While most therapy models direct that one addresses the substance abuse first and then the co-morbid condition, we suggest a re-thinking of that policy to at least acknowledge the client's underlying cause at the very least, and – in some cases – treat both conditions concurrently.
So What Do I Actually Say When a Client Discloses to Me?
We have adopted a Strengths Perspective when someone discloses – whether on a hotline call, in a psychiatric ward, at a substance abuse support group, or in the office. Identified and championed by Dennis Saleebey, the strengths perspective means that everything you do as a therapist will be based on facilitating the discovery and enhancement of the client's strengths and resources in order to help them realize their goals and even dreams.
What this means for the client is a validation of his/her feelings, trauma, and ability to survive one of the worst experiences a human being can experience. Suggested responses could be:
• "Thank you for trusting me with that information. It takes a lot of courage to say those words out loud and that tells me something about your core strength."
• "I am so sorry that happened to you. The fact that you are asking for help tells me just how strong you have been to survive – because only the strong ask for help, not the weak."
• "How terrible for you! Let's talk about how the assault affected your life and how you have managed to survive to this day."
You get the idea. The assault or childhood abuse must be addressed, validated, and the client allowed to feel that they have accomplished something – particularly if and when they reach out for help.
We will address the signs of sexual trauma, but first we want to take a look at some of the cultural myths of sexual assault that prevents most survivors from coming forward ... and many therapists from feeling comfortable in responding fully.
CHAPTER 2
Myths of Sexual Assault & Their Effect on All of Us
Imagine leaving a business meeting one evening and walking to your car to go home, laptop slung over your shoulder. Suddenly a mugger approaches from behind, knocks you to the ground, and steals your laptop. Struggling to your feet, you punch in 9-1-1 on your cell.
When the police arrive, you shakily relate what happened. The officer looks you up and down and skeptically begins to question you as to why you are on the street at 10:30 at night (because No business meeting lasts that long), why you are wearing a good suit (which is just asking for trouble), and why you didn't fight to hang on to the laptop.
Sound far-fetched? of course. Yet sexual assault survivors often face such questioning and worse in the aftermath of the crime – and not just from un-informed law enforcement. They can face it from members of the helping professions, their family and their friends.
Why? Because there are a number of myths that still permeate our culture regarding sexual violence. outstanding organizations such as RAINN (rape, Abuse, Incest National Network) and the NSVRC (National Sexual Violence resource Center), as well as individual state advocacy groups like the Pennsylvania Coalition Against rape, and most college campuses address the most common myths that can skew both a survivor's perspective and their subsequent treatment by others.
The U.S. Department of Justice Office on Violence Against Women compiled the following myths of sexual violence that have developed over the generations. We have countered with the facts.
MYTH: Sexual assault is a crime of passion.
[FACT: Sexual assault is an act of control and aggression. It is less motivated by the desire for sex (except in the thankfully very small percentage of sadistic rapists) and more motivated by the need to exert power and control over another human being. Dr. David Lisak, professor at the university of Massachusetts and leader in studies of what he termed "the undetected rapist" produced research that indicated that approximately 85 percent of sexual assaults are planned – not crimes of passion.
MYTH: You can easily identify sexual offenders.
[FACT: The stereotypical image of the rapist is that he is "abnormal" and easy to identify. In media, rapists are often of portrayed as deranged criminals and many look that way who you might see on the sex offender registry. But the majority of rapists act and appear relatively "normal" and can hold positions of respect and power. Serial "acquaintance rapists" are often extremely charismatic.
MYTH: Strangers commit the highest percentage of rapes.
[FACT: While we usually warn our children about "stranger danger," the disturbing fact is that most victims – children, adolescents, and women -- are sexually assaulted by someone they know — someone who has already been identified as safe and non-threatening. In college, acquaintance rape accounts for approximately 90% of completed and attempted sexual assaults.
Community surveys reveal that approximately 80% of all rapes, including those against males, are acquaintance rapes. And for those with disabilities, that number skyrockets to as high as 92%.
MYTH: If you stay out of deserted alleys and other isolated places, you should be safe from sexual violence.
[FACT: Sexual assaults happen anywhere and anytime. Sixty percent of assaults occur in the home of either the victim or the assailant. Sexual assaults also occur in public institutions, the workplace, schools and vehicles as well as places traditionally identified as dangerous — parks, alleys, dark streets, and underground garages.
MYTH: A victim has to say "No" for it to legally be considered a sexual assault.
[FACT: Any time someone is forced to have sex against their will, it is sexual assault. There are many reasons why a victim might not physically fight their attacker including shock (remember, most victims know and trust their rapist), fear, threats or the size and strength of the attacker.
And many sexual assault victims freeze when they are assaulted because the cognitive executive function in their frontal lobe shuts down, rendering them incapable of speech. In addition, there are many other reasons a victim might not say "no" and it is still sexual assault. Dr. Scott Hampton, Director of New Hampshire's Ending the Violence, has spent decades studying and teaching about consent issues and created "25 reasons Why Sexual Assault Victims Don't Say No." Included among them are: She is too young to know the difference; She comes from a culture where "no" is not an option; She dissociates when she is threatened; She doesn't understand English very well; and She was afraid her boss would fire her.
MYTH: You can identify rape survivors by their massive physical injuries.
[FACT: The National Violence Against Women Survey found that 69% of the victims were not injured, while 31% did receive some injuries (Tjaden & Theonnes, 1998). Many rape survivors are not visibly injured because the threat of violence alone is often sufficient to cause a victim to submit to the rapist, to protect herself from physical harm. regarding the survivor's emotional state, both the expressive (cry, laugh, pressured speech) and controlled reactions are normal (see Chapter 3).
MYTH: Women lie about rape as an act of revenge or guilt.
[FACT: only about 2% of all rape and related sex charges are determined to be false — the same as other felonies – as supported by FBI statistics. False claims of auto theft are reported more frequently than those of rape.
