Working with Couples to Address Childhood Sexual Abuse

A significant number of couples present for therapy, with one or both of the partners having experienced sexual abuse as a child. Many of the clients who experienced childhood sexual abuse have engaged in individual therapy to address the multitude of issues precipitated by the perpetration visited upon them. Individual counselling is the traditional approach to addressing childhood sexual abuse however, the impact of the abuse frequently generates relationship difficulties for example trust, of which many aspects are best responded to within the couple-counselling context. Couple counselling approaches have been successfully employed as an alternative to a therapist and an individual client working through the myriad of issues which result from childhood abuse and trauma. Emotionally Focused Therapy (EFT) is notable in the literature as a comprehensive systemic approach to working with people who have experienced trauma and abuse as a child (Johnson, 2008).

The systemic approach outlined in this article is less prescriptive than EFT and can be used to complement individual therapy, or applied as a standalone therapeutic intervention. The framework used is strongly influenced by the Metaframeworks approach (Breunlin, Schwartz, & Kune-Karrer, 2001), which is summarised at the end of this chapter. The Metaframeworks approach provides a set of theoretical ideas which create links between past and present and the internal and external worlds clients bring to the therapeutic process. Themes common to this work: safety, ambivalence and commitment are described as tending to be sequential in nature, while at the same time, possessing fluidity as they enter and exit the therapeutic process over the course of treatment.

Sexual difficulties are often present in couple counselling, and their prevalence within the sexual abuse context is exacerbated. In this article, whilst not a sex therapy manual, a number of commonly presented issues related to love and sex are illustrated within the case studies presented.

The First Session

Session One with a couple requires one and a half- two hours to complete and comprises three parts. The first part involves describing the process of working with issues related to childhood sexual abuse within a couple-counselling context. Included within this description is the ability of a couple-relationship to provide a real-life context for healing past trauma. For example, a victim of sexual abuse may find it difficult to trust another person at a deep emotional level after, for example, being abused by a supposedly loving and caring stepfather etc. Repairing such a breach of trust can hardly have a better context than in one where a person has chosen to live with another for the rest of their lives. Within this description it is important to highlight the shared nature of the counselling process and that the focus is not just on the person who has been abused more so, that the healing will develop from shared story-telling and mutuality of the couple developing understanding and intimacy.

The second phase is to see each partner individually to assess several aspects of the relationship. From a practice point of view, it is important to see the female partner first in order to ascertain if physical or sexual abuse is currently present in the relationship. If the therapist determines this is the case, the remainder of the session can be managed in a way that does not place the female at further risk. For example, the individual session with the male client would avoid addressing safety in the relationship and focus on the need for each person to engage in individual counselling to address one specific issue or another. This approach allows for female clients to develop a safety plan etc. It is clearly understood that some women are abusive in relationships however, the risk of a male partner being hospitalised etc is minimal compared with female to male violence and this thinking determines the sequencing of the session and does not predetermine who could be abusive in the relationship. Under no circumstances should couple-counselling of this nature be undertaken where abuse or the threat of abuse is present. If it is safe to proceed, the following questions are useful primers and the rationale for each set of questions is provided.

Couples often feel afraid to discuss the feelings and thoughts they have about each other. A number of reasons cause people to fear talking openly about what bothers them in their relationship. For example, you might be afraid to tell your partner that you don’t have loving feelings toward them, because they might respond by leaving you. Some people are afraid to face their own feelings and others fear their partner’s anger. Whatever the reason, people in couple therapy need to talk about thoughts and feelings in order to have the kind of relationship they desire.

• Do you feel safe enough to talk about your thoughts and feelings with your partner? If not, what stops you?
• On a scale of 1-10, how safe do you feel talking to your partner about your thoughts and feelings?
• What events/actions would increase your sense of safety?
• What actions/events would decrease your sense of safety?

Ambivalence in relationships usually means people are unsure about what they want. For example, do I want to stay in this relationship? Or, do I want to leave? Many people feel ambivalent about their relationship when it becomes mundane and/or things are going wrong for them. Facing up to the ambivalence is an important step in dealing with the issues that promote it.

Are you experiencing ambivalence? What makes you feel more positive about your relationship? What makes you feel less positive?

It requires commitment from a couple to face up to their relationship issues and to successfully work with them.

On a scale of 1-10:

• How committed are you to working on your relationship?
• What motivates you to rate your commitment at the level you have?
• What needs to happen to increase your commitment?

The third phase brings the couple back together to reflect on their thoughts re safety, ambivalence and commitment. In reporting back, the therapist’s task is to reframe what was discussed in the second phase of the interview. For example, a client may have said that they “do not trust their partner when it comes to sharing their feelings with them”. Having asked the client individually if they would like to be able to trust their partner, and if the answer is affirmative, the therapist could feedback with the couple that the client would like to develop a more trusting relationship. By identifying relational themes such as trust and intimacy, and highlighting them in feedback and conversation with the couple in a manner which signifies positive change, the therapist creates a series of threads that are woven throughout the therapeutic process. Therapists must take care in this process to be led by the client and to ensure collaborative practice is the cornerstone of the therapeutic endeavour.

The identification of key themes signals the final stage of the first session; providing a summary of the content which has been raised throughout the process and future steps for counselling as a conclusion to the process. A sense of hopefulness should be conveyed to the clients, even if the imminent future looks bleak. For example, a couple may disclose that they are on the brink of separation however, regardless of how black it seems at the moment, “you have taken the courageous first step of sorting your difficulties out”.

Subsequent Sessions

Any issues relating to safety, ambivalence and commitment are dealt with following the initial session and precede any therapy relating to the abuse. However, many clients who have experienced abuse may find it difficult to experience a full sense of safety, and a collaborative judgement between the therapist and client needs to be made regarding the question of whether it is safe enough to proceed. This approach in itself often creates an increasing sense of safety and a measure of whether to proceed may be based on the ability of clients to be respectful and caring of each other.

In the author’s experience, the number of sessions between couple’s ranges from eight to twenty and the decision to continue beyond eight is made on the couple being able to show signs of progress. Difficulty in making progress, more often than not, relates to the quality of the couple’s relationship, and referring the client who has experienced the abuse to individual counselling, while continuing to work with their relational issues may be the most responsible course of action.

Safety, Ambivalence and Commitment

The absence of safety in a relationship pre-determines the initial counselling process which is the creation of a safe and secure relationship. The absence of safety and commitment excludes the use of this couple-focused approach in working with sexual abuse. If violence exists in the relationship, safety planning, empowering an abused partner to leave the other and/or the enrolment of the perpetrator in a programme, becomes the focus of treatment. Often the treatment combines offender treatment, safety planning and empowerment of the abused person. Couple-counselling can be a useful adjunct to the above however, it should not be put in place if the violence is ongoing in the relationship.

Developing Safety

Abusive relationships aside, couples frequently report feeling unsafe sharing their deepest thoughts and feelings with one another, and the approach taken involves a continuation of the questions asked individually in the second phase of the initial interview. The use of reflexive questions (Neden, 2012 & Tomm, 1987) to begin building a safe context, evolves into a plan for action developed by the couple. For example, questions such as “If your relationship was a safe haven, how would you go about sharing your deepest thoughts and feelings with each other”, “In what way would you talk with each other?”, “What impact would talking in this way have on how you felt about one another?”, “How would this way of thinking and feeling impact on the intimacy between you both?”, “If the intimacy grew between you in the way you described, what would happen to the level of trust in your relationship?”and “If the trust between you grew to the extent we just talked about, how safe would you feel in your relationship?”

The use of reflexive questions in this context is for the therapist to support the couple to paint an intricate picture of a safe and trusting relationship and the concretisation their possible next steps. For example, questions might include, ‘what would be the first step you could each take in building this safe trusting relationship’? How could you support each other to do this’? ‘When could you start’? ‘What do you think could go wrong’? ‘What could you do to deal with that difficulty if it arose’?

It is important for the clients to make a contract with each other outlining the steps and actions they will take to increase safety in their relationship. In consolidating this piece of work the author finds it helpful to the client’s if a letter is sent as a follow-up to the session which summarises the conversation and the contract the couple developed. Without exception, the belief that clients wish to move towards a healthy and fulfilling relationships is held at all times and the reason for failing to achieve this is that they are constrained in some way. These constraints are seen as being located in one or more of the six Metaframeworks outlined in the synopsis at the end of this chapter.

Ambivalence and Commitment

Ambivalence towards a relationship is driven by numerous relational difficulties for example, conflict, lack of intimacy and love, frustration, boredom, unfulfilling sex, loneliness and hurt etc. Relational difficulties deprive couples of meaningful connection and over time, distance and isolation lead to separation or a sense of hopelessness. The antidote to ambivalence is commitment, fuelled by connection and friendship (Gottman, 2002). The exploration of what moves a couple to become less ambivalent and more committed, is central to dealing with this issue. The questions used, continue the theme started in the first session and identify which behaviours move a person towards a greater commitment to the relationship, or away from it. The identification of what could bring commitment to the relationship, illustrates a solution or way to foster positive change. Motivational Interviewing (Hohman, 2012) explores ambivalence by engaging clients in reflection on the ‘good things’ and ‘not so good things’ about making an identified change. The benefit of making the change must outweigh the cost of this change, in order for the client to resolve their ambivalence.

If ambivalence towards the relationship is identified, it is the practice of the author to spend a considerable portion of time working with this issue in the way described above. The resolution of ambivalence precedes commitment and committing oneself to a potentially difficult process is dependent on the type of contract entered into. It is unreasonable to ask clients for an open-ended, iron-clad commitment which they are unlikely to live up to. With this in mind, the contract the therapist discusses with many couples involves approximately twelve weeks, in which the couple focus on supporting each other while working to create positive change in their relationship.

When the issues of ambivalence, safety and commitment are resolved, the second stage of working therapeutically with the abuse can begin. However, the separation between the two stages is difficult to delineate, as many survivors of sexual abuse may have trust issues which, when dealt with in the couple relationship, work towards healing emotional wounds experienced in childhood.

Steps Towards Healing

1. The client’s family of origin story and the development/identification of ‘Parts’
2. The impact these ‘Parts’ play in the current relationship
3. Managing the internal and relational worlds
4. The abuse story and the impact it has had on the survivor
5. Towards healing

Two Cases in Point

James and Sandy, two forty-one-year-olds married with two children, sought counselling after James left the relationship for another woman. James spent one week with the woman he left Sandy for and returned to the relationship after he thought he had made a mistake and had become depressed; experiencing overwhelming guilt and shame. In reuniting with his partner, James started talking about the sexual abuse he had experienced aged 5-10 years, at the hands of his uncle. The same uncle introduced him to pornography which was an addiction James had struggled with since childhood. James was an elder in the church and prior to leaving his wife, used to view pornography and masturbate up to seven times a day. The couple were referred to the author by a family therapist to help James deal with his addiction to pornography.

Cheryl and Joe, two thirty-six-year-olds married with three young children were referred to the author by a Couple and Family Therapist, due to a number of issues relating to Cheryl’s childhood sexual abuse remaining unresolved. In addition to the relationship counselling, Cheryl had engaged in individual counselling over a number of years to resolve issues she identified as originating from the abuse and trauma she experienced as a nine-year-old child. The presenting issues included a high level of conflict in the relationship, Cheryl’s lack of trust in her partner to support her emotionally, a lack of intimacy and little or no sexual contact between the couple.

The Clients’ Family of Origin Story and the Development/ Identification of Parts

The couple are informed that they are to become observers of each other’s lives in a special way, and the importance of this is that deeper understandings create relationships which provide a context for healing past hurt and trauma. Each person is interviewed separately, while the other looks on. It is important for the observer to be silent and they are asked to imagine what it would have been like to grow up in that family? Trust, love and warmth, caring, respect, availability, understanding gender roles and belief in self are some of the themes which are explored during this part of the session. The author interviews the survivor of abuse first, as this seems an obvious fit for the clients in so much as the presenting issues relate to the abuse and trauma.

The client is asked to choose a time that comes to mind when they were growing up in their family. They are asked to describe family members and talk about the kind of relationship they experienced with them. Questions such as “How would you describe your relationship with your mother/father etc?”, “Who did you feel closest to?”, “How did your mother and father relate to each other?”, “What did you learn about being a man/woman from your mother/father?”,” What did they teach you about your self-worth?”, “How did they teach you this?”, “What kind of feelings did this evoke?” and “What did you learn from them about how to relate to members of the opposite sex?” are asked. This type of questioning is usually conducted at a measured pace and tends to transport clients back into the reality of the past, with the client and the observer typically becoming very engaged in the process.

Joe and Sandy

In the case of James and Sandy, it emerged that James’ father was cruel and emotionally abusive. For example, he used to tell James how ugly he was and made hurtful comments at the table, such as, “pass me the salt, big nose” or “you’re so ugly, no girl will find you attractive”. On the other hand, James was favoured by his mother; however, she did not show him warmth through hugging or touching. James described his childhood to Sandy, talking about how the conflict between his parents and his experiences of emotional abuse led him to withdraw into himself, feel worthless and compartmentalise various aspects of his life. He talked about how he learned from his parents to portray one-self as being a devout Christian outside the family, while living differently within it.

During the therapeutic conversation, James’ development in his family of origin was discussed in terms of a ‘Part’ of him which learned to withdraw from conflict hurt and abuse, while another ‘Part’ self-soothed through masturbation. Other ‘Parts’ learned how to pretend that James was confident etc; while in the background he was left feeling worthless as other ‘Parts’ of him sought love and acceptance.

Sandy also grew up in a religious household and her sister was sexually abused by a member of the family’s church. Sandy’s mother refused to go back to the church while her father continued to be part of the congregation. This created a rift in the family and engendered considerable conflict between Sandy’s mother and father. Sandy took her father’s side and believed her mother’s actions created disharmony and unhappiness in her and her family’s life. A ‘Part’ of Sandy believed mothers should never create dissension in the family, while others blamed her mother, feared conflict and worked towards maintaining peace at any cost.