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Section 14
Stages of Child Sexual Abuse Treatment: Part 2

CEU Question 14 | CEU Test | Table of Contents | Child Abuse
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In the last track we discussed the first two stages of the Healing Cycle, for children living with the secrets of childhood sexual abuse: exposing the wound and re-experiencing the trauma; as well as the use of the Body Scan Exercise.

This track will discuss the last two stages in the healing cycle, externalizing the pain and healing the wound. At the end of this track we will look at the use of creative drawing and writing "unmailed" letters. Even though you may be currently using these techniques, you might evaluate my use of them as compared to yours.

Stages 3 & 4 of the Healing Cycle

Stage # 3: Externalizing the Pain
As you are aware, for survivors of childhood sexual abuse to heal, their pain must be brought from the unconscious to the conscious. When externalizing of the pain, the third stage of the healing cycle, emotional pain is released, defenses weaken and feelings often times are displayed.

Jenny, age 17, remembers being sexually molested between the ages of four and seven by her older brother, Austin who was 20 at the time. She remembers telling her Mom at the age of seven. Although her parents insisted Austin move out at that time, there was no discussion about what had happened to her. Through the years, Austin visits regularly and no one has ever spoken of the situation since. Jenny entered therapy reluctantly on the advice of a trusted adult friend, when she explained her reasons for wanting to avoid all family get-togethers. Although Jenny remembers being abused, she did not realize how deeply she had been affected.

Let's look at an excerpt of a group session, where Jenny worked on externalizing her pain:

Jenny cried out, "It's hard to breathe and my heart is pounding! I feel cold, I'm scared!"
I replied, "Jenny, you're experiencing a memory. You're safe here with the group. Do you want to continue?
Jenny replied, "Yes, I want to go on. I want to finish this."
I stated, "OK, is there anything you'd like to say to your brother, Austin?"
Jenny sobbing as she hit a pillow cried, "Why did you do that to me? I feel dirty and ashamed. You stole my childhood. I hate you! I hate you!"

Jenny was able to externalize her feelings by physically hitting the pillow, sobbing and raging as she released all the bent up energy from her fear, anger and grief. Afterwards Jenny recalled more of the specifics of the abuse; details she hadn't remembered before blurting them out in therapy.

Externalizing can be facilitated by using "the unsent letter" or artwork exercises, which we will explore at the end of this track.

Think about your Jenny. Could she benefit from physical or quiet expression while externalizing her pain?

Stage #4: Healing the Wound
As you know, after externalizing the pain, the last stage is to actively heal the wound, which can bring transformation as feelings of empowerment return. When Adam, age 17, came to therapy he had experienced violent sexual abuse from his first foster mother, Sue for five years before being moved to another home.

Dr. Barabara Bogorad, wrote in her article Sexual Abuse: Surviving the Pain, "There are many commonly held beliefs about sexual abuse. One is that abusers are always men. The fact is, at least 5% of abusers are known to be women. Another myth is that the abuser is usually a stranger. More than 70% of abusers are immediate family members or someone very close to the family."

In working with Adam, I found that each meeting had to be met with flexibility as there were times when he consciously wanted to work on his anger towards Sue, his foster mother, and found issues with his natural mother surfaced. As you are aware, it is quite common for clients to move from one traumatic experience to another. This "bouncing around" does not take away from the healing work that is occurring. With every completed healing cycle experienced, Adam found the power of his pain diminished. It is as if a pressure cooker valve is opened slightly.

Each completed cycle releases a little more pressure, until core defenses have dropped. Adam reflected on his story when he stated, "I feel such a relief. I know I have experienced more abuse than I can remember. I'm so grateful that I don't have to go back and experience everything to feel better! The little I do remember is frightening enough!" Consider your Adam. Is his progress bringing him visible relief?

Technique: Creative Drawing
As Jenny worked on externalizing her pain, I had her use creative coloring or drawing to give her an additional medium to express her feelings. I asked her to create an abstract picture of herself, letting the colors represent her self-love; daring to use bold colors to express strong emotion.

This creative expression gave Jenny an opportunity to express the love she once had for her brother and the anger she felt toward him because of the abuse.She explained afterward, "As I drew, I could feel a healing power well up in me. It was weird. A release. I never thought I could express myself that way, but when I did, I was amazed how the bright colors brought definition to what I was thinking and feeling."

Technique: "Unmailed" Letters
When I asked Adam to write an "unmailed" letter, it provided him the freedom to say things he would never have dared say out loud and safely communicate all his emotions. As you know, the freedom gained by not having to defend or explain what he had written allowed a window into his repressed emotions and feelings.

On this track, we have reviewed the last two stages of the healing cycle, externalizing the pain and healing the wound; as well as, how using creative drawing or writing "unmailed" letters can provides an alternative avenue of expressing repressed feelings, thoughts and emotions in a non threatening way.

Peer-Reviewed Journal Article References:
Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965–971.

Ensink, K., Borelli, J. L., Normandin, L., Target, M., & Fonagy, P. (2020). Childhood sexual abuse and attachment insecurity: Associations with child psychological difficulties. American Journal of Orthopsychiatry, 90(1), 115–124. 

Ferrajão, P. C., & Elklit, A. (2020). World assumptions and posttraumatic stress in a treatment-seeking sample of survivors of childhood sexual abuse: A longitudinal study. Psychology of Violence, 10(5), 501–508. 

Webster, G. (2018). Psychoanalytic complexity theory: An application to the treatment of child sexual offenders. Psychoanalytic Psychology, 35(1), 83–92.

Wolfe, V. V. (1992). Review of Child sexual abuse: Critical perspectives on prevention, intervention, and treatment [Review of the book Child sexual abuse: Critical perspectives on prevention, intervention, and treatment, by C. R. Bagley & R. J. Thomlison, Eds.]. Canadian Psychology/Psychologie canadienne, 33(2), 211–212.

Online Continuing Education QUESTION 14
What are two techniques you could use to help your client externalize pain? To select and enter your answer go to CEU Test.

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