Sanctuary for the Abused
Thursday, March 16, 2006
Survivor Issues in Group Therapy
By Catherine McAlpine, LCSW-C, and Barbara McCormick, LCSW-C
In 1989, we began working with female survivors of childhood sexual abuse in small, supportive groups. Survivors frequently feel isolated and believe that they are unique in being subjected to the trauma of abuse and the associated neglect, loss of trust, and loss of self-esteem. Survivors often face post-trauma symptoms of depression and anxiety, and have trouble maintaining personal relationships. In bringing women together in structured, confidential, and supportive groups, we help survivors "normalize" their experiences and post-trauma responses to abuse, and enhance their progress in individual therapy. Factors that influence the group members' feelings and self-images are recurring topics for discussion in survivor groups.
The Healing Process
As therapists we have listened to and learned from dozens of women who have called or met with us for consultation and those who have spent many hard, painful hours in therapy sessions. We have consistently been struck by the depth of commitment these women have made to moving beyond their feelings and experiences of victimization to a sense of wholeness, competence, and strength. These women have been devoted to their own work while being sources of strength and encouragement to each other in group.
As with other forms of human or self-development, the process of healing occurs along a spectrum. Phases are not separate, distinct steps: they are more of a gradual back-and-forth movement toward wholeness. Imagine the ebb and flow of a tide washing upon a shoreline. Movement is subtle, change is gradual. There is a state of constant motion.
Groups are powerful therapeutic tools for sexual abuse survivors. Providing an opportunity for recovery and developing self-awareness in the context of relationships are essential to healing. The tasks of the group allow for identification and understanding of post-trauma symptoms; personal development of the core self; socialization; and a practice arena in which to test new emotions, thoughts, and actions. Additionally, the influence of and validation by peers who have similar life experiences and the genuine ability to "know what it was like" are freeing and healing forces for the survivor. No longer isolated and "different," the group members join together around their common secrets and shame.
We begin our groups by helping each member develop goals upon which to focus as they work within the group. This process is handled in a confidential and supportive manner. Each person writes down her areas of concern. These notes are collected, and members participate by reading an anonymously written issue. This initial step enables all members to participate without expressly disclosing their own experiences, thus avoiding the anxiety of direct personal disclosure. In the process of discussion, members move toward a consensus of group goals. Shared and agreed upon tasks are important for establishing an agenda for the group's therapeutic work. Group members immediately experience a sense of relief and the dissipation of feelings of isolation.
The dynamics of families in which sexual abuse occurs include family rules of "don't talk" "don't trust," and "don't feel." As survivors define their personal recovery goals, recurrent themes that encompass the stages of healing (included within the broad categories of self-esteem, power and safety, trust and intimacy, and developing feelings or an emotional repertoire) emerge. These form the foundation of survivors' lives. The process of group therapy allows women to experience relationships that are caring, reflective, and validating. Through the transference and mirroring of these relationships, personal growth and progress toward wholeness are achieved.
Worthlessness and Guilt
Typically, children raised in abusive families experience emotional deprivation as well as physical abuse and neglect. This absence of caring relationships further complicates how survivors view themselves and intensifies problems with development of self-esteem and feelings of self-worth. When one parent is perpetrating abuse, survivors frequently receive little nurturing or positive feedback from the non-offending parent, who tends to be emotionally absent and has few resources to help the child develop. Understanding these dynamics helps survivors build the confidence and self-care skills necessary for recovery.
The post-traumatic effects of sexual abuse distort beliefs in how the world responds to survivors and their perceptions of how they fit into their families, social situations, and work environments. Feeling good about oneself, one's body image, and one's sexuality are often concerns for survivors. It's difficult to feel positive about oneself when the physical pain and emotional confusion inherent in sexual abuse is perpetrated against a child who has not yet developed a strong sense of self. Survivors' experiences teach them that they are not able to control what happens to their own bodies, and that their bodies may be dirty. Many survivors disassociate from physical feelings as a result of the abuse. It often seems like an insurmountable task to survivors to perceive themselves as healthy sexual adults later in life or even to cope with feelings of sexuality.
Improving confidence, independence, and care of oneself is a necessary step for survivors to improve their self-esteem. Feelings of worthlessness and guilt need to be closely examined at the root and then challenged. Understanding the impact of abuse on the self-worth and how this has delayed growth through appropriate developmental stages is an important task for survivors. Education is essential for survivors to reach genuine understanding.
In addition, guilt is often experienced by survivors because they perceive that they have participated in sexual abuse or allowed it to occur. They may feel shame because they have not disclosed the abuse, or perhaps they have enjoyed the physical sensations of the body's natural responses to it. Sharing this shame in group allows identification with others as well as emotional release. Disclosures often help dispel feelings of shame about the abuse. If not dispelled, guilt and self-blame may cause survivors to sabotage themselves or act out when progress occurs.
Powerlessness and Lack of Safety
The dynamics of childhood sexual abuse require the victim to surrender to a perpetrator. A more powerful person imposes his or her will on the child. This person is trusted and looked upon by the child as the model or mirror of what is normal and correct in behavior and perceptions. Boundaries within the self and in relation to the outside world are violated. Control and the safety of one's body are not learned. Feelings of being safe are never experienced.
Survivors often express this experience by taking care of others, more than themselves: "If I say no to what others want from me, they will leave me" or "I can't stand up for myself." Therefore feeling okay about saying no and being in control of one's life also emerge as recurring themes in the group. Upon entering group, survivors often discuss how they have given all that they can give. The need to learn to give back to themselves in a safe manner becomes the focus of therapy.
Discovering and experiencing boundaries in their personal lives are shared and tested in a group setting. Other group members support and encourage changing behaviors. Developing ways to keep safe while feeling and becoming more effective in relationships leads to letting go of the past. As the group moves together through this process, trust in the group grows. The individual learns that it is right to be self caring. Internal and external boundaries are defined in relationships. Most importantly, group members learn to trust themselves and their inner voices.
Lack of Trust and Intimacy
Survivors develop defenses against a world and relationships in which they have experienced repeated violation, abandonment and assault. These necessary defenses often have the secondary effect of preventing or inhibiting intimacy. Survivors may have frequent, intense but brief relationships or may tend to the other extreme of total isolation. Although survivors may crave normal physical and emotional closeness with others, their defensive patterns and lack of basic trust may prevent such intimacy.
In therapy groups, survivors have identified the desire to feel less alone as one of their goals. Having felt themselves outsiders, different from others because of their abuse and shame, survivors now want to break through their isolation. They are ambivalent about their desire for closeness, however, because of years of failed relationships. Having decided to risk making the connections inherent in individual and group therapy, survivors have identified their need for others as a means toward recovering the self.
Group therapy allows a survivor to experience a number of relationships in a controlled, limited way, which allows gentle exploration and self-expression. There are opportunities to try out new patterns of thinking, feeling, and behaving with little danger of backlash or attack. Established patterns of avoidance and nonconfrontation are challenged. Survivors begin to feel validated in making these changes and build some basic trust in themselves and others. The learning or modeling component of group therapy allows survivors to learn from each other and to visualize the support of the group when testing new patterns in "real" life. These positive experiences allow for a generalization from the group to specific relationships, then from specific relationships to the larger context.
The most difficult places for trust and intimacy to develop are in close friendships and with sexual partners. Survivors often split into public and private selves. They have learned to present an image which is designed to protect the 'true" self from hurt and abandonment. This defense, which was developed as a means of protection, becomes a barrier to closeness in the process of healing. An intimate relationship or emotional bond is impossible through the barrier of a false self. The removal of this mask is a slow process of "check-share-check" through which survivors are slowly able to reveal parts of themselves in an honest way while maintaining a sense of safety.
Therapists are familiar with dissociative disorders and defense mechanisms, such as repression and denial, employed to deal with overwhelming feelings. People develop the strategy of splitting their minds from their feelings as a necessary response to an external or internal threat to the self. Children who experience a reasonably safe and loving environment do not need to separate their cognitive and emotional selves. Because of the efficiency of dissociation, survivors often have a hard time identifying and voicing their feelings. Survivors describe themselves as being a "talking head and shoulders," not being aware of physical pain, and not having an emotional response until hours or weeks after an experience.
Building connections between thinking and feeling can lead to crisis for the individual. Feelings are sometimes described as an iceberg or glacier that suddenly thaws. The intensity of sadness, guilt, rage, grief, fear, or disappointment is a flood of repressed physiological and emotional responses.
In the past, allowing these emotions to emerge was too threatening to a survivor's sense of self. Often, expressions of feeling were followed by experiences of abandonment and rejection or by an impulse toward self-harm. The therapy group provides a safe environment in which intense feelings can be expressed without loss of love or security. The ability of other survivors to identify with and accept these intense emotions "normalizes" the individual survivor's experience. The expression of highly charged content allows the survivor to work through both the cognitive and emotional elements of their lives. Bringing together the head with gut feelings facilitates integration.
As healing progresses, negative and strong emotions become less threatening. After a period of intense affective expression, a more moderate level is reached. Emotions are expressed as they occur. There is less need to hold back or repress experiences. The reliance on dissociation is replaced with strategies more consistent with the present. Moderation of intense feelings allows for greater intimacy and attachment with others.
Recovery from childhood sexual abuse is the process of bringing forth the parts of self that have been damaged by abuse, neglect, and deprivation. Tasks of the healing process are accomplished as survivors gain control over their personal and emotional lives, establish boundaries as well as bonds in relation to others, and can feel more alive. Group therapy provides a safe, supportive environment in which survivors at all stages of healing can learn from and help each other.
Catherine McAlpine and Barbara McCormick are therapists who have worked extensively with survivors of childhood sexual abuse.