Working With Survivors of Sexual Abuse and Trauma

PRACTICEWorking With Survivors ofSexual Abuse and Trauma:The Case of AngelaAngela is a 27-year-old, Caucasian female, who first came tocounseling to address her history of sexual abuse. She graduatedfrom college with a BS in chemistry and has since been employedby pharmaceutical companies. After obtaining a new job, she relocated to an apartment in an East Coast city where she knew noone. Both of Angela’s parents live on the West Coast, and she hasone younger brother who also lives in a different state. Angela haslimited contact with both her mother and brother and does nothave any contact with her father. Angela is obese and discloseda history of struggling with her weight and eating issues. She hasfew friends, and those she does have live far away.Angela has a long history of trauma in her life. She was sexuallyabused between the ages of 9 and 21 by her father, sexually assaultedat the age of 14 by a classmate in school, and mugged as a youngadult. There was domestic violence in the home, also perpetrated byher father. Angela’s father is considered an upstanding member ofthe community, and he is well liked and respected by others. No onein Angela’s family believes that she was sexually abused, and herfather joined a “false memory syndrome” group and is outspokenabout that issue. There has been little discussion in her family aboutwhat took place in the home while she was growing up.Angela struggled with daily functioning and exhibited symptoms of post-traumatic stress disorder (PTSD). She had a historyof cutting herself and binge eating and displayed some characteristics of borderline personality disorder. Angela also mildlydissociated when under duress. Angela suffered from depressionand anxiety and had trouble establishing new relationships, bothsocially and at work. Although Angela has a stable job and wasable to complete her work each day, at times she became overwhelmed by her emotions and retreated to the bathroom whereshe cried and sometimes cut herself before returning to her workstation. Angela relied on writing, artwork, and her cat for solace29SOCIAL WORK CASE STUDIES: FOUNDATION YEARand comfort. She was also very active outdoors, often hiking,biking, and going on camping trips by herself. Her goals in lifewere to own her own home, lose weight, enjoy relationships withothers, and find peace with her traumas.As a result of the abuse she experienced, it was necessary tobegin treatment focusing heavily on establishing trust and a relationship with the client. After 1 year of therapy, deeper processwork was being done around her traumas, and she was able toopen up much more. She disclosed more painful experiences tothe therapist and began expressing her feelings, including intenseanger at her family members.Angela also joined a group for survivors of sexual violence inthe same program where she was receiving individual therapy.She was thus able to meet other survivors and engage them inrelationship building and obtain support. Over time, she lost100 pounds and made new friends, and her level of functioningincreased dramatically. Six months into the group, however, Inoticed boundary issues between the members of the group andthe group facilitator. After speaking with the group facilitatorabout these concerns and others regarding her clinical judgmentand boundary crossing, the decision was made to terminate her.As a new group facilitator began engaging the group, I noticedthat Angela was not sharing as much in her individual sessionsand, overall, seemed guarded. I tried on numerous occasions toaddress the shift, and while Angela acknowledged that trust hadbecome an issue, she would not directly express her concerns orfeelings. After some discussion, I explained to Angela that while Icould not discuss the issues concerning the group facilitator, sheshould feel free to talk about her feelings and concerns in general.However, it became obvious that trust could not be rebuilt, particularly in light of the professional boundary issues with the groupfacilitator. I asked if she wanted to terminate counseling with meand find a new therapist, and Angela agreed. I provided Angelawith three referrals so that she could continue her treatment. Ilearned that Angela and the former group facilitator had becomefriends and remained so after both had left the program in theirrespective capacities.30APPENDIXReflection Questionsactivities as Veronica did. She went to school every day and didnot appear very different from other children in her area. It isimportant to note that families in poverty-stricken countries likeGuatemala are deceived by traffickers who offer them moneyequivalent to a year’s income in exchange for their children. Allthe details of this case are not clear as of yet but it is believed thatthe maternal aunt was working in conjunction with someone else.9. Describe any additional personal reflections about this case.This was a hard case to digest. It is one of those cases that youend up taking home with you in your heart. This 13-year-oldgirl has been through a lifetime of exploitation. For the first fewweeks she would just look at me as if she were looking rightthrough me. She needed a lot of coaxing to participate. Althoughshe still has a great deal of healing ahead of her, Veronica is in amuch better place and is making every effort to live a normal life.Working With Survivors of Sexual Abuse and Trauma:The Case of Angela1. What specific intervention strategies (skills, knowledge,etc.) did you use to address this client situation?Knowledge of trauma and child sexual abuse was key as wasactive listening, validation, boundary setting, and, at times,confrontation.2. Which theory or theories did you use to guide your practice?I applied relational, cognitive behavioral, empowerment, andstrengths-based theories.3. What were the identified strengths of the client(s)?Angela’s strengths were her ability to persevere and be resilient, as well as her ability to find time for self-reflection andself-care. Despite everyone around her telling her otherwise,she was still able to stand firm in the knowledge that she wassexually abused and therefore needed to have clear boundarieswith those who did not believe her.4. What were the identified challenges faced by the client(s)?Angela’s challenges included an occasional inability to functionat work, self-harm, and isolation.105SOCIAL WORK CASE STUDIES: FOUNDATION YEAR  5. hat were the agreed-upon goals to be met to addressWthe concern?The goals were to increase functioning, enhance ability tocreate and sustain relationships with others, reduce isolation,address and increase self-esteem, refrain from cutting, andwork through early sexual trauma.  6. hat local, state, or federal policies could (or did) affectWthis situation?The statute of limitations in both civil and criminal casesaffected Angela’s case.  7. ow would you advocate for social change to positivelyHaffect this case? would advocate with legislators in the state to eliminate theIstatute of limitations so that survivors of sexual abuse couldprosecute and/or sue their perpetrator when they were ready.  8. ere there any legal or ethical issues present in the case?WIf so, what were they and how were they addressed?There were ethical issues regarding boundaries and dualrelationships. The group facilitator in this case was inappropriate with her clients and became personal friends with thisparticular client along with the other women in the group. Iaddressed this by trying to work with the group facilitator, aswell as by encouraging her to discuss this in her off-site clinical supervision. Because no change was occurring, eventually the group facilitator was terminated.  9. ow can evidence-based practice be integrated into thisHsituation?The use of a sequenced, titrated approach using relationaltheory to address complex PTSD is incredibly helpful, especially for those survivors of sexual trauma with multiplevictimizations and difficulty with daily functioning.10. escribe any additional personal reflections about this case.D the individual therapist, this case was heartbreaking forAsme. The relationship and trust I had built with this client wasdestroyed, and I was placed in a very precarious position. Theclient did not want to discuss the changing dynamic and had106APPENDIXclearly been influenced by the group facilitator, who was ­ncrediblyifriendly and outgoing. There was no other choice but termination,and the realization that the damage could not be repaired wasdisappointing. However, had I disclosed “my side” of what washappening, I would have been making the same errors as the groupfacilitator and involving myself in a dysfunctional and unhealthydynamic, including crossing boundaries—exactly what survivorsdo not need. There are times when you must “swallow your pride”to do what is right and best for the client, especially given thedifferent variables and considering the ethical issues at play.Working With Survivors of Sexual Abuse and Trauma:The Case of Brenna1. What specific intervention strategies (skills, knowledge,etc.) did you use to address this client situation?I used reflective listening and reframing to assist Brenna insetting goals and determining her unmet needs. I used knowledge of local systems and social service agencies to providereferrals and to secure needed services.2. Which theory or theories did you use to guide your practice?I utilized systems theory.3. What were the identified strengths of the client(s)?Brenna’s strengths were her resiliency and self-sufficiency.Brenna viewed her desire to provide a better future for herchild as a strong motivating factor for changing her life.4. What were the identified challenges faced by the client(s)?Brenna lacked a familial support system and network of friends,and she was socially isolated. Upon entry to the shelter, she lackedmedical care, employment, income, and housing. Brenna also struggled with difficulty reading and writing. Brenna had experiencedtrauma and violence in her past and would be raising her child alone.5. What were the agreed-upon goals to be met to address theconcern?Brenna and I agreed to secure medical care, a housing plan,and a source of income. Brenna also set goals to improve hermental health.107