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Section 13
Stages of Therapy for Adults Sexually
Abused as Children

Question 13 | Test | Table of Contents


STAGE ONE: THE VICTIM ACCOUNT
As in all psychotherapy, a successful relationship between therapist and client is crucial to therapeutic success. As it begins to take shape in survivor therapy, as trust and cooperation form, the client is prepared to begin the journey to self discovery. In the initial stage, the therapist helps the client, whatever her current understandings, to construct a victim account about her experience. To do so, the therapist takes the client through a series of reinterpretations in which she slowly detaches herself from and deconstructs her previous account and identity. Therapists understand and explain these reinterpretations as a dismantling of the defenses and coping mechanisms that the client erected as a child to deal with the trauma of abuse and that now express themselves in her conscious and unconscious resistance to see her victimization and to change. The process begins with the therapist helping the client to remember childhood sexual episodes.

STAGE TWO: THE SURVIVOR STORY
In the first stage of therapy, the therapist led the client to give an account that emphasized vulnerability, powerlessness, a false identity, and psychological defenses and coping mechanisms that have blocked genuine self-awareness. In this account, the client is victim. In the second stage, the therapist again leads the client to tell a story about herself, but now the time frame shifts. Therapy is moving away from a concern with the past to a concern with changing the way the client presently views herself and lives her life. To build a sense of agency and spur the client's motivation for the next steps, the therapist emphasizes her strength rather than her past powerlessness. She suffered trauma, he tells her, and lived to tell about it. She is, therefore, a "survivor:' possessor of the inner resources that enable victims to persevere. To persevere, therapists argue, is to resist the complete obliteration of the "true self:' the original self that is strong and healthy: "Even though a client may describe that 'true self' as bad, stupid, ugly, or weak, the therapist knows that at the very core of this adult rests a beautiful and powerful child who is a pivotal resource for healing" (Roth 1993: 88).' In the words of another therapist, "[T]he very term 'abuse survivor' emphasizes the fact that the victim persevered despite her or his psychic injuries; ... this resilience and willingness to struggle should be reinforced and relied upon by the therapist, whose task is lessened by the existence of the 'strong, healthy part' in most survivors" (Briere 1989: 6o-6i). In emphasizing a "strong, healthy part:' the therapist communicates to the client a central therapeutic idea: The story of her life is really two stories. One story, victimization, signifies the part of herself conditioned by abuse and expressed in her symptoms and other problems identified during therapy. The other story, survival, signifies the part of herself that has remained true and that is expressed in her inner strength, resilience, and willingness to struggle. The telling of the survivor story begins with the therapist leading the client to affirm that she possesses the survivor qualities, and because she has them, she has the power and can expect to heal.

Beyond building a sense of agency and expectation of positive change, the therapist uses the idea of a strong, healthy part as a symbolic resource for the reinterpretations that constitute the survivor story. In stage two, the therapist takes the client through a process of reframing her view of herself and others in light of the survivor rationale. The therapist has already led the client to link her adult problems with childhood abuse and to commit herself to reject all that being an abuse victim entails. Now he works to identify a broader pattern of deviations from therapeutic norms in matters of the client's sense of self-worth, the way she manages her personal boundaries, the coherence of her identity, and her social skills and relationships. In the process of decoding her life according to the survivor rationale, the therapist persuades her to see problems with the way she is living that go well beyond the issues that brought her to therapy. He creates for her a fuller picture of the "false self" that, he argues, has informed and divided her identity. The false self is the benchmark against which the therapist contrasts the true self. By describing this true self as embodied in a strong, healthy part within her, the therapist positions his teaching as the natural drawing out of a story and a reality that were always present but heretofore unrecognized and unexpressed. The idea of a strong, healthy part suggests that by collaborating with the therapist, the client is authoring an undistorted account of her unique self. Because of the strong part, not only the victim story but also the survivor story has narrative fit for her life.

The survivor story is a story of personal change, a story about overcoming the conditioned responses of the false self. Building on the idea of her "survivor strength the therapist emphasizes risk-taking, experimentation, efficacious action, personal development, and new possibilities for relationships. As in the victim account, where the therapist has the client act out key elements of the drama-for example, remembering, expressing anger, disclosing, grieving-so in the survivor story, he will lead the client to act out a new way of knowing and possessing the self. These actions are the preconditions for telling the story and create experiences that can then be conveyed in it. A new reflexive relationship to the self, including skill with the authorized "technologies of the self" - techniques for managing emotions, interpersonal relationships, the body, and so on- for living this reflexivity, is the key sign of healing. A new sense of her self-worth is where the next story begins.


STAGE THREE: THE THRIVER STORY
The survivor story is a story about reversing the present effects of the past. For therapists, the client can tell the story when she has internalized the therapeutic norms and techniques and is acting on them-when, in other words, she can describe the effects of the past and how she is overcoming them. When she can tell the survivor story, healing has been largely realized and its signs can be observed: "Healing occurs when the client has achieved a reasonable level of resolution around the abusive events, has unraveled the resultant distortions of self and reality and replaced them with healthier views, has learned new skills that were not taught in childhood, has the ability to establish and maintain positive relationships, and has an experience of herself as efficacious in her world" (Roth 1993: 24). The steps of the survivor story, including the confrontation, have been addressed to achieving these goals. With the telling and retelling of the survivor story, therapy nears its end.

Although principally framed as a story about growth and healing, the survivor story is built directly on the victim story about abuse. Survivor strength is defined in terms of resistance to abuse, and personal change in terms of overcoming a self conditioned by abuse. As therapy moves toward its denouement, therapists encourage clients to move beyond the view of themselves as survivors. Abuse remains a part of their story, but because they have made and are making desired changes in their identity and consequent behavior, clients "no longer need to define themselves in terms of their experience of childhood sexual abuse" (Draucker 1992:116). Thus, "Counselors, in the later stages of treatment, might well discuss with the client the process of giving up the survivor identity" (ii6). At this advanced point in therapy, the transitional stories of victim and survivor have accomplished their purpose. The therapist now readies the client to end therapy and reincorporate into normal life with a positive, thriver story, which moves abuse and overcoming abuse to the background. He does not ask the client to let go of the thriver story but to embrace it as the ongoing story of her life. When therapy ends, the thriver story is just beginning.

The thriver story is the end of the mediating narrative and its climax. It is the conclusion that is anticipated throughout the process of constructing the narrative, guiding the building of the therapeutic relationship, the selective recruitment of past events (whether real or imagined), and the interpretation of present life circumstances. It is the goal, the lesson toward which the whole narrative builds and takes its meaning. It is the promise used to motivate the client and justify her efforts to part with old understandings and patterns and learn new ones.

The thriver story is a story of liberation. According to the plot of the mediating narrative as it has unfolded in the victim account and survivor story, the pathological secret has been identified, and its effects progressively overcome. The hold of the past on the client has been broken; she has been freed from who she was, freed from the wrong story, freed from encumbering relationships, and has the power to become someone new. In the thriver story, she is free to let her true self flourish fully for the first time. She "is ready to infuse her life with new hope and new choices" (Roth 1993: 65). She can live with new vitality and satisfaction, express her creativity, enjoy intimacy, and define her goals and strive to reach them. She can become who she wants to be and do what she wants to do. In the thriver story, the future is unscripted, open and full of possibilities.

The therapist emphasizes themes aimed to confirm her transformation and motivate her to continue to act according to the new norms and relationship strategies she has learned. By linking her old ideas and behavior with abuse, and by framing his teaching in terms of health and normal development in the survivor stage, he has already made a forceful case for not returning to old or other patterns. Moreover, because the survivor story represents a commitment to a continued course of action, ordering her self and renegotiating her relationships through that story constrains the client to continue to act in a manner consistent with the commitment. In the thriver story, the therapist connects future growth and vitality with a steady living of the new story and emphasizes themes of self-determination and responsibility to reinforce it.

In leading the client to tell the thriver story, the therapist contrasts two journeys, one now nearly complete and another about to begin. In the first journey toward healing, the client has moved, via the mediating narrative, from a life that was abuse-determined to a life capable of being self-determined, from a life shaped by domination to a life empowered with agency. In the second journey, she will move into the future choosing her own path. For the second journey, as thriver, she no longer needs to depend on the guidance of the therapist. She is ready, he argues, for "healthy separation" (Courtois 1988: io). Although "it is all right for the client to have needs again" (Roth 1993: 70) that might warrant a return to the therapist, any such return in the next journey would be qualitatively different and temporary. She is now, the therapist tells her, able to reflexively direct her own journey. He has taught the normative orientations and a technology of the self that equip clients to become their own therapists. The therapist's message is that if the client follows these new principles, she can do for herself in the second journey what he did for her in the first.

Because she is believed to be self-determined, the client is also now responsible to herself for her life and her choices. While the past may have been outside her control, and thus she is blameless with regard to it, in the journey that begins with the thriver story, things are different. In the new journey, she has "total responsibility for her own destiny" (Draucker 1992: io8). She is becoming an individual, free of false consciousness, and therefore able to shoulder the burden of responsibility for all aspects of her life. The victim account was an "excuse:' an "appeal to defeasibility" (Scott and Lyman 1968) of responsibility for the problems the client has experienced, because her will was not free. To tell the thriver story, she cannot make any further excuses. If she continues to live her new identity, therapists imply, she will never need to.
- Davis, Joseph, Accounts of Innocence: Sexual Abuse, Trauma, and the Self, University of Chicago Press: Chicago, 2005.

Update
OVC FY 2023 Improving Outcomes for Child
and Youth Victims of Human Trafficking

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Personal Reflection Exercise #6
The preceding section contained information about stages of therapy for adults sexually abused as children. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Peer-Reviewed Journal Article References:
Brienza, A., Suffoletto, B. P., Kuhn, E., Germain, A., Jaramillo, S., Repine, M., Callaway, C. W., & Pacella-LaBarbara, M. L. (2021). The role of specific sources of social support on postinjury psychological symptoms. Rehabilitation Psychology. Advance online publication.

Pulverman, C. S., & Meston, C. M. (2020). Sexual dysfunction in women with a history of childhood sexual abuse: The role of sexual shame. Psychological Trauma: Theory, Research, Practice, and Policy, 12(3), 291–299.

Wiener, R. L., Berry, M. C., Wertheimer, J., Petty, T., & Martinez, J. (2021). The public’s judgment of sex trafficked women: Blaming the victim? Journal of Experimental Psychology: Applied, 27(3), 529–545.

QUESTION 13
In leading the client to tell the thriver story, what two journeys does the therapist contrast? To select and enter your answer go to Test.

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