‘What factors would a therapist take into account when planning treatment for a psychologically abused client?

8 August 2016

I feel that dealing with clients who are the survivors or current victims of abuse is the most intricate and sensitive subject I have studied. Emotional and physical abuse of children and adults can take place at any age, in any country or culture and at any level of society. Forms of abuse are hugely varied and can be motivated by many factors including sexual gratification, control, fear or even love. Psychotherapists have offered a variety of ways to plan treatment for a psychologically abused client, in this essay I will examine the factors that I would take into account in treating such a client.

In doing this I will examine the term psychological abuse and the ways in which it occurs in society and with this understanding, plan appropriate treatment. I will also explore the different approaches to therapy; from cognitive behavioural therapy, rational emotive behavioural therapy, person-centred and psychodynamic, that the therapist can choose from their therapist’s tool box. There are also practical considerations for the therapist to consider in the initial consultation that may well have contraindications and ethical dilemmas for the therapeutic process.

‘What factors would a therapist take into account when planning treatment for a psychologically abused client? Essay Example

Dealing with psychological abuse may even bring into question the therapists own competence as well as dealing with the abused clients own resistance to the therapeutic process. It is a multi-faceted complex process when planning the treatment for a psychological abused client. As abuse can be something that has the potential to affect an individual throughout their lives, I feel it is a subject that demands consideration, safe and ethical practice and a great deal of self awareness on behalf of the therapist in order to avoid actions that could prove counterproductive,

invasive or even damaging (to the therapist’s life as well as the client’s). I feel that helping to facilitate change for a sufferer of abuse is an important role to play in a person’s life and could therefore have the potential to be both very rewarding and also extremely draining for a therapist if the appropriate considerations are not met. Psychological abuse: Esther Giller defines psychological trauma as “a traumatic event or situation creates psychological trauma when it overwhelms the individual’s ability to cope, and leaves that person fearing death, annihilation, mutilation, or psychosis.

The individual may feel emotionally, cognitively, and physically overwhelmed. The circumstances of the event commonly include abuse of power, betrayal of trust, entrapment, helplessness, pain, confusion, and/or loss. ” Victims of this type of abuse are left struggling to cope and deal with their trauma and that brings about an overwhelming emotion and a feeling of utter helplessness. This helplessness can be difficult to understand for most people and just how deeply it affects individuals.

Psychological abuse is often perpetuated by ones own family unit and happens in many types of families, although it is more frequent in homes where there is family conflict, multiple stresses, physical violence, mental health issues, depression or substance abuse. In such circumstances the client may feel that they are trapped and has no choice or option to exit the abuse and are left with inadequate defenses. This is particularly true when adults abuse children which can become part of their life script if abused in childhood. People from all walks of life and ages can be susceptible to psychological abuse.

However, the characteristics of psychological abuse are common they are, repeated, unpredictable, multi-faceted and sadistic. Abusers use a variety of tactics to manipulate and exert their power through dominance, humiliation, isolation, threats, intimidation, denial and blame. According to the American Academy of Pediatrics (AAP) position statement on psychological maltreatment, psychological abuse in young children can be just as damaging in terms of the children’s physical, mental and emotional health than physical abuse like punch, kick or slap.

According to Dr. Harriet MacMillan, a professor in the departments of psychiatry and behavioral neurosciences and pediatrics of McMaster University’s Michael G. DeGroote School of Medicine and the Offord Centre for Child Studies, exploiting, belittling, terrorizing or denigrating a child or being emotionally unresponsive as well as corrupting a child to the point where a child’s wellbeing is at risk are all forms of psychological abuse.

Scientific literature has described psychological abuse over two-and-a-half decades ago, yet MacMillan states that it has remained under-recognized and under-reported and that the impact of psychological child abuse “can be as harmful as other types of maltreatment. ” Psychological maltreatment has an impact on the development of children. Psychological abuse is therefore associated with various problems, including disorders of attachment, developmental, educational and socialization problems as well as disruptive behavior.

Macmillan goes onto say “The effects of psychological maltreatment during the first three years of life can be particularly profound. ” Unlike the few existing studies that report on the prevalence of psychological abuse, the position statement reveals that large population-based, self-report studies in the UK and the U. S. have discovered that around 8 to 9% of women and 4% of men reported exposure to severe psychological abuse during childhood.

Psychological abuse is like self-harming & self-defeating behaviours; people acquire self-defeating coping strategies and continue to employ these behaviours even after the abuse is over. So the person’s inherent character and personality is affected and they lose their true identity. Those experiencing psychological abuse may have very low self-esteem where they used to be confident, they exhibit major personality changes, become depressed, anxious or suicidal. For those that have been psychologically abused in childhood the effects can be severe and long-lasting.

It is the disturbance of a child’s sense of safety and security that produces this quite often this is centred around a childhood of an unstable/unsafe environment, separation of a parent, sexual, physical or verbal abuse, domestic violence, neglect, bullying, serious illness and intrusive medical procedures. For the psychodynamic theorist Bowlby, the quality of attachment between mother and baby affects the adult they become to feel safe in the world, trust others, cope with stress and rebound from disappointment.

This early psychological abuse disturbs the attachment bonds and results in adult relationship difficulties. Bowlby (1988) suggested that attachment style can change through self-reflection or corrective relationships. The therapeutic relationship is one whereby this change can occur as it acts as a ‘secure base’ so that the client/therapist relationship parallels the outside world attachment patterns. So in planning a psychologically abused clients treatment issues of attachment within the therapeutic hour would seem to be very important for psychodynamic therapist.

Jon Allen (1995) a psychologist says that a therapist should be aware of two components centred on a traumatic experience the ‘objective and the subjective’ “It is the subjective experience of the objective events that constitutes the trauma… The more you believe you are endangered, the more traumatised you will be. ” So the focus of treatment is defined by the experience of the survivor. Psychodynamic theorist Mann (1990) puts further shape on this idea in the client’s story, he says it isn’t what the client tells but the where, when and the how of this story is broken down.

Mann puts forth two central questions that the therapist must bear in mind when planning treatment firstly, how is the story told? Secondly, what can the client allow themselves to know, feel and remember in telling the story? In doing this the therapist needs to create a non-judgemental environment where the client can express their needs without fear of rejection. Or a psychodynamic approach, where there should be an initial flexibility in boundaries so that it disconfirms the client’s prior experience of inconsistent responsiveness. Boundaries that are too rigid may make the relationship unsafe.

Of course this is almost in antithesis of the cognitive behavioural approach to therapy but maybe ultimately quicker in results than the lengthy process of psychodynamic therapy. Time and money are big considerations when planning a treatment programme for a client. If the client is limited in these bounds then there may be a compromise on the type of therapeutic programme that is offered. The goal of traditional psychotherapy is to reprocess painful experience in the hope of changing the way the client sees himself and his loved ones, which will then, hopefully, bring about positive change in behaviour.

Psychotherapeutic approaches can however be criticised as solely focusing on the mental state at the expense of the physiological effects of psychological abuse. These physical symptoms are wide ranging from insomnia to nightmares, being startled easily, fatigue, palpitations, difficulty concentrating, edginess, agitation, aches and pains and muscle tension. A therapist will need to take into account when planning treatment the impact that the physiological is having on the client’s psychological wellbeing. A more holistic approach would need to be adopted.

Also, the therapist needs to bear in mind the social implications that a psychologically abused client may be suffering. They may be having difficulty functioning at work and home, be unable to form close and satisfying relationships, be emotionally numb and disconnected from others or perhaps be using alcohol or drugs to make them feel better. However, most psychotherapeutic treatment seeks to get the client to face and resolve the uncomfortable feelings and memories that they have long avoided. So they process the abuse related memories and feelings, discharging the fight or flight energy and building/rebuilding

the ability to trust people. Psychodynamic counselling helps a person to understand the role of their past in their current situation and the victim to understand the situation of that the abuse many have or is experience; whereas, cognitive behavioural therapy works with the victim to change behaviour. Especially when trying to remove them forms an abusive situation or when looking to their future and the relationships they form. For Beck he suggests that CBT therapy removes the triggers to the problem, thereby reducing the psychological arousal and challenging their negative thoughts.

From this point they are able to modify beliefs and change behaviour. With a psychologically abused client it is common for anxiety and panic attacks to manifest themselves as an aspect of trauma. The use of CBT as discussed earlier is extremely effective in challenging these disorders. Linda Sanford writes in Strong at the broken places that of her case studies of those suffering from childhood psychological abuse but seemingly outwardly strong people, many of them still suffer anxiety and panic attacks at night. The fear of being attacked again or its consequences produces this.

The cognitive model of panic disorder treats these perceptions as more dangerous than they are realistically. Clarke (1986) and Wells (1997) put forth a cyclic pattern to panic attacks whereby the trigger stimulus feeds off apprehension producing body sensations that interpret the sensations as catastrophic. Then safety behaviours develop to prevent the feared catastrophic events from occurring. The cognitive model sees the physical symptoms as an indication that something is wrong the use of diaries as an assessment of the symptoms. It will eventually guide the client into adopting a self-help approach.

Cognitive therapists employ an active-directive style that is goal-orientated, problem solving and structured approach. The prime action of this treatment planning is change. The skill of the therapist lies in being a good educator to enable the clients to understand the relationships between cognitions, emotions, physiology and behaviour. So the client is taught to monitor reality tests and modify their dysfunctional and distorted beliefs. Person-centred counseling is very good in building rapport with clients that suffer psychological abuse.

This therapeutic alliance is effective in creating the ‘safe environment’ to build trust and allow the person to feel safe and valued. However, this is normally the foundation stone of all modern therapeutic techniques. To use it solely in therapy is a lengthy treatment process. The use of rational emotive behavioural therapy in psychological abuse can be empowering for the client. Using the ABCDE model the client identifies their beliefs and thoughts around the abusive incident and consequences of their thoughts. Thus they move forward and dispute their irrational thoughts and create an effective new way of dealing with the situation.

Conceptualising this client’s presenting problem in planning treatment, the therapist firstly needs to examine the psychopathology of the problem. By this I would conduct a formal assessment in the initial consultation. It would involve the use of my clinical experience, intuition and rather than just objective criteria. This is an on-going process throughout therapy that can be reviewed. Lemma (1996) suggests that one should introduce the client to the purpose of assessment and its boundaries, then allow the client to take the lead by asking questions about their ideas on their presenting problem.

In getting the client to elicit responses the therapist should be able to gather information that gives a clear indication of the onset of the problem, cause of it, any predisposing factors, precipitating factors and perpetuating factors. This will then all give a ‘formulation of the presenting problem. ’ From this point the therapist can then offer the client therapy or refer them onto another agency. Also the therapist when planning the treatment for a psychologically abused client needs to assess their own competence (a contraindication) to tackle the client’s presenting problem.

Sometimes the therapist may need to consult their supervisor when considering their ability to cope with the client’s problem. This maybe an ethical minefield even for the therapist, for example if they are dealing with someone who has suffered child abuse but wants to talk about their own thoughts and feelings about wanting to pursue it. The psychological abuse may also be close to something the therapist too has suffered and they may not want to take on the client due to what it will bring up in their selves.

Also with a psychologically abused client the therapist may find the client to be ‘resistant’ or ‘non-compliant’ this could really affect the therapeutic alliance. If this psychologically abused client is being seen through a problem specific agency such as a rape crisis centre or an alcohol treatment centre it can be taken for granted within the agency that is a singular compound problem rather than something that is masking other serious problems such as child abuse, depression of PSTD.

These agencies often attract clients that are experiencing multiple problems. It is also difficult to form a therapeutic alliance with a person who fears exposing their vulnerability as victims of psychological abuse feel. The therapist can also face ethical dilemmas as they may sometimes validate their client’s feelings about their partner’s behaviour as ‘appropriate’, for the sake of the therapeutic alliance and because of the therapist’s fear that it may stop therapy and making progress.

This may strengthen the client’s validation for the form that the psychological abuse is taking. Again, ethically the therapist needs to be aware of what is going on in the therapeutic alliance. Also to compound all this it has been noted that generally most therapists believe what their clients tell them even when they know they are receiving just a part of the whole story and a distorted version of it. Ethically the therapist needs to be vigilant about the client’s allegations of abuse.

As sometimes the client’s perceives the abuse to be true but can be highly distorted and they can be highly convincing to others. Conclusion: Clearly people are not meant to suffer psychological abuse and as such are not equipped to understand the abuse that happens or the emotive response. Unresolved trauma from psychological abuse can involve highly adaptive behaviours which have become coping strategies. These can eventually cause problems in the body, mind and essence of a person so treating a patient is an incredibly complex process.

From a therapist’s point of view planning treatment there are many more factors that I could have mentioned but we should look to Gardner (2001) who says that it is “the goal of therapeutic work is to translate this suffering into conscious communication, so that understanding and insight is gained. ” In treating psychological abuse in psychotherapy the challenges the therapist faces are multi-layered but also very specific to the client one is treating. The therapist is expected to make their judgements based on the client’s best interests and what is within their moral framework and professional ethical framework.

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