 We demystify what goes on behind the therapy room door. Join us on this voyage of discovery and co-creative conversations. This is The Therapy Show, behind closed doors podcast with Bob Cook and Jackie Jones. Welcome back to The Therapy Show with Bob Cook and me, Jackie Jones. And what we're going to be looking at this week, Bob, is the sexually abused client or working with somebody who has been subject to it? Yeah, that sort of traumatic invasion of the psyche, body and emotional spirit. Yeah, yeah. Would you say that as an exposter carer, we can learn about sexual abuse, emotional abuse, neglects, all those sorts of things. Would you put all those together or do you think somebody that's been sexually abused is unique in certain ways? Well, they're certainly unique in certain ways. And also, if you could put it under the line, you could put it under the label of trauma, because they're all various stages of trauma. And there is a uniqueness, I think, to sexual abuse, but there's also a generalized processes around trauma. So, yes and no, William, I know we've got two podcasts, but we'll just aim, I think, at the sexual abuse treatment and then we can do another one on trauma. But you are correct in the sense of, you know, we're talking about generalized trauma in quite a big way. I'll splitting it off, but, you know, we could say this is trauma, but I'd like to just split it off for the moment and look at the treatment plan of sexual abuse, and then we'll move on to the traumatized treatment plan. And there is similarities, but there's also a unique difference, I think. Yeah. Would clients, you know, from your experience, come with that subject in mind? Yes. Okay. So I've worked for many decades and people, I couldn't say how many clients I've worked for sexual abuse, but often come with the consequences of, you know, as people being sexually inappropriate or abusive with them. Yeah, because any of my clients, it's kind of unfolded, you know, during the time that we've spent together, they haven't actually come with that topic, if that makes sense. They've come with, you know, panic attacks or anxiety or, you know, not working well as a couple or, you know, relationship issues. And then it's kind of unfolded as we've been seeing each other. They haven't actually come with that issue. I'm just... Well, to answer your question, yes, I've seen many, many clients who've come specifically with sexual abuse and sexual inappropriate. Trauma, and I've also seen many clients where some of the things they've come with in terms of mistrust or flashbacks or panic attacks has unfolded to trauma and specifically sexual abuse. So it's not either stroke or, but I have seen many clients who specifically come with sexual abuse issues. Yeah. Yeah. It is a big subject, you know, like I said, having been an ex foster carer. It's something that, you know, it's one of those things, I think, that as a society, we like to think that it doesn't happen, but the reality is none of us know what goes on behind closed doors. Well, I mean, you know, a lot of sexual abuse takes place in care homes. I mean, you're on the best place to know that from your history. And also, we know from all the, you know, the, the, the reportings in the newspapers. Yeah. So, I mean, I could sit here and talk about care homes and things we're talking about in depth. I get really saddened when I hear about how many people get abused in care homes and it's a nominal lot. And what's incredibly sad is that the very people are supposed to look after them. Are the very people then go, then go on to abuse them. Yeah. Which is kind of like a general theme with abuse of any description. Usually it is somebody that, you know, you put your trust in. Yeah. However, in care homes, particularly people who usually go to care homes have been abused in many ways before that, maybe sexual abuse, maybe, you know, extreme loss, maybe physical trauma. So they go to care homes usually from a place of vulnerability. And those people who have been working there are often the people then go and retraumatise them all over again. Yeah. Yeah. And as, you know, particularly with, with, you know, young people, I suppose grooming comes under this as well. But, you know, it's a slow process. So in the therapy room, again, you know, there's, there's blocks to building up a relationship with somebody. They're going to come in, not trusting anybody, I would have thought. Or the opposite, were they overdressed? Yeah. Yeah, because they're having no sense of protection and boundaries. But so you absolutely correct there. However, let's start with, if we're looking at treatment of sexual abuse, let's start with what you just brought up there, which is what they present with. And the number one place to start is to build up a working relationship in a therapeutic environment where the trust can be built up again. Yeah. Well, we can get to the other side later, which is often where they are over trusting and over, you know, over sort of encouraging, if you like, in another way around. I mean, in that type of naïve, naïve, naivety. But let's start with the clients who come in with great mistrust and great fear. The therapist needs to understand how long that will take in a way and in the attention of gentleness by the therapist and that type of belief in slow therapy. In other words, what I mean by that is that the therapist needs to be very, very patient and understand the invasion and the complete breakdown, usually, of trust by the client. Yeah. And that is really, really very important, which means, by definition, that treatment of people who have been sexually abused or as sexually inappropriateness takes a long time because of way, way at the beginning, you need to spend time in building up trust. So that's how you need to do that is to spend a long time in what in CA they were called script analysis. The psychoanalysis, they might call formulation. Either way, it's learning about the person's history and finding out about a bit about them, the consequences of their lives today, of the abuse, the things that are happening to them in the present now, which is part of the legacy of the abuse. So a lot of fact finding and gentle for helping the client tell their story. And in that way, the person hopefully will start to build up some trust, which is the bedrock of dealing with the invasion of trust. Yeah. At a fundamental level. Yeah. Now, you are right. The other side of that is the client that comes in and is so open and so over trusting, because they've never had any people that's really been caring of them or shows the money trust in the first place. So they don't have any knowledge on how to keep self care or to take care of themselves. So it's very, how can I explain it? The therapist needs to help the person be aware of that and not overwhelm them too quickly because they're very vulnerable people. Yeah. Yeah. What would you advise the clients if, you know, they've never spoke about this before, if, you know, the perpetrator has never, you know, taken responsibility for their actions or something. But if we talk about people come especially specifically with sexual abuse, they know they've been sex abuse. So therefore, they will have an inkling of the perpetrator. And usually, and I'll say usually because the research backs this up, it's usually people they know or people being part of the family. So, you know, it's going to be a father, mother, grandfather, sibling, friend, you know, babysitter, friend of the family. So they have an inkling of when they were, an inkling of when they were sexually abused or they've got a story of who the perpetrator is. So, you know, a good question to ask, but it's when you say to how you say it is a is another thing because timing's key here. But a good question to ask is, did that person go to prison? Yeah. Now, that will bring home the seriousness of what they may or may not think as serious. Yeah. And, you know, for me with the clients where it has come out at some point is, you know, that they if they haven't notified anybody that they can still do that now, even if it's 10, 15, 20 years ago that this, this happened. Yeah, you know, you certainly could give them that information and say, well, that's interesting. And so, is this something you want to take further in the present day? And usually they don't. Or they, they will deal with the history first. And out of that may come strength to be able to take things further. But usually, it's around the talking about their story and the healing process before you go any further. Yeah. Yeah. Sometimes you get people of course who have taken their perpetrator to court and they want to deal with the ramifications of all that. Yeah. That's another whole story. Yeah. But if we look at some of the symptoms of sexual abuse, I put a list and did this podcast and I've got a few here. I've started off with fear and mistrust, which I was just talking about that. Another one, which is very common is panic attacks and anxiety. Yeah. And of course, flashbacks. Yeah. Now, if we look at flashbacks, you get flashbacks, where the person doesn't actually know why they are, you know, why they are anxiety. So they might get flashbacks, which is simply horrific pictures or might get anxiety, but they don't have cognitive awareness of the flashbacks. They can't actually talk about what was the incident that is associated with the flashback because there's a disconnection. Yeah. So you might get flashbacks without cognition, or you might get flashbacks with just purely emotional. Or you might get flashbacks, which are actually just come out in the body if you want to put it that way. But there's a disconnection usually between the emotional recognition and the thinking. There's a disconnection there. So you get anxiety, panic attack, flashbacks, nightmares, things like that. And they're very incapacitating. I was just thinking about post-traumatic stress, if you want to put it that way, the post-traumatic stress that comes with the flashbacks, which is so incapacitating to a person's life. So I might be walking down the road, and I don't know, there's a scooter that makes some noise and it triggers off a flashback. Then they go into fear of palpitations and anxiety, and they don't know why it's happening. Yeah. Yeah. Which, you know, to start to unearth all of this and put the pieces together, you know, and bring it into the present. Again, there's a danger of them being retraumatised by things. Yeah, it's a very fine balance. You know, I've got a few more here. So after, you know, it's poor self-image. Yeah. And with that huge self-esteem issues, there's usually a feeling of self-worthlessness and that they have no value. They often get depressed, often high paranoia. And they feel quite often completely worthless and dirty. Yeah. So they present with all these, or some of these issues we're just talking about here. You know, and then we need to get down to a little bit about, you know, what was the abuse and getting down to some of the stories and help them connect thinking to feeling and flashbacks. And yes, it is a very gentle, slow process. Because unless you go in that sort of level, then they will get overwhelmed and could get retraumatised. Yeah. Now there's a difference between retraumatisation and what I would call reliving. So you can help people tell their stories without them going to a place of reliving the trauma. And that's a very fine balance. Yeah. Yeah, because with these clients, there's certain sort of methods that you wouldn't use with them in a therapy room. Yeah. So for example, you wouldn't, you might really see yes and no. So, you know, I was going to say you wouldn't get these clients to do two chair work and talking to the perpetrator. That's the one that sprung to my mind when I said it. I hesitated because you might do that much later on in the therapy in a whole process of them taking power against the person who actually abused them. But to get to that place is long way, it's a long way down the road. It may or may never have to be the case. However, that's why I hesitated. However, the first step really is getting help the person tell their story, help the person build up therapeutic trust in the therapist. Before we go on to the next stage, which I would probably call retrieval of memory. So if we look at the first stage, which is building up of therapeutic trust, right? Yeah. The next stage, we could call the retrieval of memory stage, if you wanted to call it that. And in this particular stage, the therapist will concentrate on what we can call in the business, phenomenal logical inquiry, which is what I've just talked about with you, which is helping the person tell their story, help them go further into their history, helping them put thinking and feeling together, helping them make connections between cognition and what's happening in the body, and helping them gradually retrieve some of those memories, which has been so horrific for them. So if you think of say a honeycomb, if you look at a honeycomb, there's lots and lots and lots of compartments. Yeah. What happens with the trauma that goes around the sexual abuse is the trauma or the feelings or the invasive thoughts gets put into one of those compartments, people shut the door. Yeah. Understandably. Yeah, because because reliving that in any way, those thoughts or those emotions are so overwhelming, that that can often be a then a psychosis or a psychological collapse. So the natural coping mechanism is to shut off that part of themselves, which has been so damaged. Yeah. And then to get on with life as best they can. The problem is that all those emotions and thoughts and trauma which has been locked away in the compartment. As time goes on, the door starts to creak. And it becomes harder and harder to keep the door shut. Yeah. And that's when you get flashbacks. And that's when you get a leakage out. And unless that compartment is open, gradually, and there's an actual investigation inquiry into all those emotions and thoughts and help the person contain those emotions and thoughts. If there's not a deep cleansing of that process in that compartment, then what happens is there's a lot of energy, energy being spent closing that door, impossible eventually to hold that pressure cooker in and the door opens. And then the person gets overwhelmed. And then they capacitate themselves. And then we start to see all those symptoms we talked about earlier. Yeah. So the treatment is to help the person open the door gradually with the therapist, in a way that the person can handle the emotions and the thoughts in a contained way and process it in a contained way with support. So they don't feel that they're going to collapse and have to go in some sort of incapacitated psychotic place. Now, this takes a tremendous lot of time. So when I talk about the retrieval of memory stage, I'm talking about the stage where the therapist is helping the client open that door a bit of that compartment and start processing some of those emotions and thoughts which haven't been discussed, haven't been connected before in the surface, in the service of the savior of the soul. So the therapist is very gradually helping the therapist, sorry, the client deal with what was also unmanageable before. Yeah. Yeah, because you know, from my experience, what I've worked with when you said, you know, something that wasn't manageable before, usually we're talking about young, young children in this situation. So there's that complete lack of control and, you know, the blaming shame that goes along with that. So, you know, talking to the adults in the here and now, with all the feelings and emotions of a younger child in them, it can be overwhelming quite quickly. Yeah, very quickly. And what the next stage is what you're talking about, really, as they start to make connections and emotions and thoughts and behavior and the trauma, they will then convey quickly moving to what I would call the emergency phase, which is where they get flooded with emotions Yeah, and get overwhelmed. And I said this stage that the therapist needs to help the client make sense, what was an talkable about. Yeah. And that might mean at that particular stage, two sessions a week, or even three sessions a week, because at that particular stage, when they start to open the door to the trauma and abuse, which has been locked away so they could survive, they may feel so overwhelmed by the feelings or the thoughts that functioning becomes difficult. Yeah. So that's where you would perhaps do some emergency extra sessions to help the person process what was so unpostable before. Yeah. And, you know, again, in my experience, lots of lots of grounding techniques and metaphorically holding them, slowing it down so that they're not overwhelmed in the session. Lots of grounding techniques. Yeah. Yeah. That's particularly a stage you're after helping them really what you've just said really ground themselves contain the process, heal themselves through the repetitive talking out their abuse, making sense of what happened, is tempted to make sense of what is often ununderstandable. So they have a narrative which is soothing to myself. And that's, that's the time where they get so overwhelmed that you have to do grounding techniques with them. Yeah. And this all takes time. This isn't something to be rushed at all. No, no. Definitely not. And, you know, I've had kind of both sets of clients where one, you know, they want to get to the end line as quickly as possible, and to try and, you know, maintain the pace and let them know that this isn't just opening the door fully and having a route around and that's it. You know, we need to slow this down so it doesn't matter how long it takes to do this and keeping themselves safe in the process. You know, going right back to the earlier podcast that we've done having enough adult capacity to, to maintain and cope with having that door open to a certain extent. Yeah, absolutely. And, you know, it's, speed is not the aspect of therapy. This is about what you've just heard. Slow, bit by bit. It's a process, not an event. No, no. But I think, I think, you know, some people particularly with something traumatic, it's kind of like, we'll just get through it as quickly as we can so I can get to the other side of it, because it is, it is difficult. Yeah. And the other thing, of course, what's just going to happen is usually they regress. Yeah. The time, the developmental time when the actual trauma happened. Yeah. So that's something really important to bear in mind, the developmental age they're going to regress still. And yes, are you right? Again, they want to speed up and get it all over with. But the problem with that is unless you do the real work that's needed to be done and cleanse out the trauma, or at least help the person work through the trauma, then they'll be back in your consulting room within six months. Yeah. Yeah. 100% agree. Yeah. So the next stage of the emergency stage is the integrating of new decisions and behaviors, I think. So as they start to make connections that emotions, thoughts and behaviors, as they start to hopefully make sense of what was understandable. And as they start to look at their earlier decisions as ways of coping at that particular time, rather than everything's their own fault or feel shamed, etc, etc. And as I start to put new healthy decisions in place, and start integrate that in their life. Again, this takes time. But that's what I see as this stage. Yeah. Yeah. Putting new show on the road. Yes. Yeah. And at what point would you say that, you know, getting in touch with the younger self and kind of making peace with their selves? What phase would you say that's in that emergency phase? What do you mean? Well, I have to know what you mean, Manny. What do you mean by making peace with their younger part of the self? Well, a lot of the times when I'm talking to clients that have been through trauma, it's about, you know, they question the decisions that they made when they were younger, whether it's the blame and shame. And I kind of say to them, but you did the best that you could with what you had available at that time. So it's about making peace with maybe the decisions that were made around the trauma, whether that was sexual or something else. Yeah, adults, we would probably make more adult decisions. But as a young child, we do whatever we need to survive. Yeah, yeah, that would come really more. Yeah, more into this stage that we're talking about here. Yeah, the new decisions, the integrating of the healthy processes, other than the emergency phase, which is really about containing feelings. Yeah. So what you're talking about here would definitely go into this stage. Yeah. And again, that takes quite a lot of work because having to Well, I have to stop. How can I explain this? It's not like forgiving themselves. But what if you've been told it's your fault, it's your fault, your fault. Eventually, the your becomes an I, and they think they're at fault. So it's really, it's really a time when you need to get to a place where they can start realizing that none of this was their fault in the first place. And then from that place, I think our self esteem can start to grow. And from that place, they can start to put hopefully new healthy behaviors in place. And this is where the therapist needs to be much more directive, perhaps, than they've been in the other stages. Yeah. And talk to them about what new healthy decisions are, and help them integrate these new healthy coping mechanisms into their life today. Yeah. Yeah, because there's going to be an awful lot of self doubt there. You know, what if we're talking about, you know, trust issues and everything, there's going to be an awful lot of, you know, can I trust the decisions that I'm going to make now as an adult? Yeah, that's right. And it's at this stage of the therapy that you might, I'll say might in a reserved way, do two chair work, because it's this stage of the therapy where the interjects or the persecutors can rise, can sort of like rise their heads. Yeah. And say, well, you deserve this. In the first place, you're asking for you were just a slut, or you were this, or you were that and or you were whatever it is. And that this might be a stage where the therapist needs to help the client split out, you know, from themselves and the persecutory narratives. Yes. And to take power back. Yeah. Because when you were saying that the persecutor will kind of pop up again, or you're not talking physically, you're talking metaphorically within themselves in the brain. Yes. Yeah. Yeah. Yeah. I'm talking about the narrative in their head. And what they've taken on board and assimilated. Yeah. And what they may say, well, I'm hearing my other self, of course, turn myself off. And this sort of toxic narrative, which has been so so embedded may raise its head. Yes. Yeah. And the way to take power from that is, I think, is to chair techniques where the therapist puts office protection and support to stand up to the perpetrator who's been so abusive to them. Yeah. And to take power back. And like you say, this is weird on the road. Well, we're now onto nearly the last page. Yes. Yeah. We're way down. It's after they've done, you know, the containment work, the making connections, separating out thoughts and feelings, doing the detoxifying work, doing all that. So we're way down the line now. Yeah. And I'm not sure how you feel, but I kind of see this as a bit like grief, that it's not always a linear process. It can be, you know, one step forward and two steps backwards. And, you know, it's not, this is a process. And this is how we do it, that they might do some of it and then need to go back to the beginning again. And, you know, yeah. Yeah, absolutely. This isn't a linear process at all. These are stages which I'm sort of stating because of this podcast and hopefully will help people listening. But what you just said there is really important because they may go to, well, any stage you like, they can move to mistrusting you and thinking that you're trying to trick them and then you slide back to stage one. So yes, it's not linear at all. No. But for anybody in training that's listening to this or anything, it's really nice to have a process and see the end place. But it's, you know, you don't hang on to it for grim death, thinking this is how we do it. It's every client is unique and different in how they get there. That's correct how they get there. However, I do think the, I do think with trauma, there is a splitting off of the psyche. In other words, for the person to get through the trauma, they need to survive and the best way they can survive psychologically is through what I would call a splitting phenomena, where a person splits off the trauma to survive. Yeah. So I think there has to be a process where they take back what they've cut off. Yeah. In other words, they start with the therapist helping, with the therapist dealing with the disconnections so they can get a connected unification hole. Now, how do you do it? Yes, I quite agree with you. It might go through many of those stages in different ways, but you see, I think to get to a hole, the person needs to understand their disconnections. Yeah. Yeah. So in other words, to get to connection, you have to go to disconnection. Yes. Yeah. And that's why I say that one of the stages might be that you would, through two chair technique, help the client take back parts of themselves, which they split off. Yes. And to do that, may need to stand up to the perpetrator with your help of protection, the therapist's help of protection, so they can take back a part of themselves, which they necessarily have to give away, so they feel much more whole and much more powerful in charge of their own destiny. Yeah. Yeah. So the next stage after this, we could call termination and endings. So they started it, they've told their story, they dealt with the connections, they've started to understand the understandable, talk the untalkable, they stood up to the perpetrator, they've taken back parts themselves, which they've given away. Now we need to move to a place of how to end, how to end in therapy. Now that's really not, now this is a really tricky bit really in many ways because you've been their protector, their saviour and their anchor throughout the whole process. So this is a, this is a stage which needs to take time, where needs to be talked about and needs to be done in a very respectful, honouring way. Yeah. No, are you okay now? Goodbye, nothing in the opposite of that. Yeah. Because in reality, you're the safety, you're the safety net, you've been there throughout it all to, to hold them and to catch them. Usually what I do at this stage by the way is do a very lengthy review. Yeah. But where they came in, where we've gone, what we've done and taking real account of their achievements and their celebrations. Yeah. You know, in other words, how are they going to celebrate the new self? Yeah. Because letting go is, is going to be difficult. I don't want to you know, make assumptions but it is going to be quite difficult for them to let go. That's why I do a review and I centre a lot on celebrations. Yeah. They've achieved their courage there. See, to do this work takes courage. Yeah. Particularly brave. And it's not a straightforward process. It's far better in the end, of course, the, the, the, the person comes to therapy and deals with all this a lot, but it takes a lot of guts, you know. So it's really important, I think, to recognise and to celebrate the person's real success in this work. Yeah. Yeah. 100%. Because, you know, to be vulnerable takes massive amounts of courage and to work through what they're doing. The two always come together in my mind. We can't be courageous without being vulnerable and vice versa. You can't be vulnerable without being courageous and it takes massive strength to go through therapy. And, and, and a real concentration on their celebration. Yeah. I think is a, a good part of an ending process. Yeah. Yeah. I like that. I like that in any ending. And it's about new beginnings. It's not, you know, we need to let something go sometimes in order to move forward and start the next phase, so to speak. Yeah. And then you can say, look, you know, if you find things particularly difficult, give us a win. Yeah. You know, it's not about they never have to come back again. It's, but it is an important process of them standing on their own feet and recognising their successes and achievements so they can get a different type of quality of life. Yeah. And, you know, it, it is a kind of a mark to be part of the decision to separate out. You know, they're making a conscious decision that I'm choosing to end therapy now. It's not done to them, you know, and they're not outcast and everything else. And that in itself can be quite therapeutic that they are actually a part of the termination. They've not been abandoned. They've not been left. Yeah. The journey's been a sense of togetherness. Yeah. So the ending needs to be a sense of togetherness. Yeah. Which for a lot of people will be quite a new experience. Yeah. But pretty, but yeah, you're right. And particularly invigorating, I think. Yeah. Yeah. It's, yeah. It is. Okadoki. Yes. That's wonderful. So what we're going to look at next is the traumatised clients. Yeah. You see, that's always splitting off a bit because I do think that's a treatment plan I or a series of stages I wanted to talk about in terms of how you work with sexually abused clients. Now, of course, you know, we are talking about trauma because, you know, there's nothing, you know, but you know, height of trauma has been sexual abuse. So they go together. However, this, the next podcast will be about how we deal with the traumatised clients. And that may cover a lot of things like physical trauma and, you know, the carous trauma and post-traumatic stress. And I specifically want to look at some of the techniques we haven't talked about here for dealing with trauma in a different way. Yeah. Okay. Till the next one, Bob. I shall speak to you soon. Okadoki. Bye. Bye. You've been listening to The Therapy Show behind closed doors podcast. 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