Long term psychotherapy for victims of child sexual abuse with learning disabilities

Royal College of Nursing Conference 1999: Alan Corbett, Head of Clinical Services, Respond

This paper will focus on the provision of long term psychotherapy for people with learning disabilities who have been sexually abused. It may be helpful to begin by providing some background context information. I work for Respond, a voluntary sector organisation which works exclusively with people with learning disabilities who have been sexually abused. Our referrals comes from a wide range of sources - social workers, care managers, community nurses, gps, probation officers and families, to name a few. We were formed in the early nineties as a response to a paucity of treatment to learning disabled victims of sexual abuse.

DESCRIBE RANGE OF SERVICES

- Individual psychotherapy Groups Risk assessment Investigative assessments Training Supervision & Consultancy Research by the University of Kent in 1993 highlighted the exposed vulnerability of people with learning disabilities to sexual abuse. This research stated that there would be at least one thousand new cases of sexual abuse where the victim has a learning disability each year. It is a horrifying statistic, but one, which I fear, is just the tip of the iceberg. In considering the treatment needs of people

with learning disabilities, we should first consider the factors in play, which increase their vulnerability to being sexually abused. Dr Dick Sobsey, a researcher from the States, claims that, if you have a disability (not just learning disability) the chances of being a victim of abuse rise by fifty per cent compared to the non disabled population. The reasons for people with learning disabilities being more vulnerable to sexual abuse are manifold: People with learning disabilities occupy a low place in our society. Resources are poor, and many of the settings, in which people with learning disabilities live and spend their days, lack the safeguards which should be essential to ensure safety against abuse.

The low status of people with learning disabilities is mirrored by the low status accorded to those working with them. Workers are all too often on low wages, receiving little or no training or supervision, with the bare minimum of police checks in place. The growth of small group homes following the resettlement of people with learning disabilities from long stay institutions is laudable, but, as yet, not regulated enough. The ability of many people with learning disabilities to access sex education is hampered by a number of factors. As a society we are still not good at considering that people with learning disabilities are sexual beings.

All too often the response to the sexuality of someone with a ld is to deny, thus making it all the more difficult for people to access education which would be geared towards ensuring inappropriate touch of any kind is understood for what it is, and can then be protected against. Another long-standing problem has been our difficulties in judging whether someone with a learning disability has been sexually abused. Many of the cases referred to Respond come with a worryingly long history of signs and symptoms of sexual abuse which have clearly been misdiagnosed.

The non verbal client who for years has been slashing his arms following abuse by a member of staff. The arm slashing somehow became seen simply as part of his behaviour, enmeshed within his learning disability. The woman with moderate learning disabilities who suffered years of sexual abuse from her father. Struggling as she was with immense feelings of shame and guilt, she became clinically depressed, spending most of her time in her day centre rocking back and forth in her chair.

Again, this behaviour became part of her label - the woman who rocks. What was missing from both settings was a culture which encouraged such behaviour to be viewed in the context of symptoms - that there must be a root cause to all behaviour, and that we are simply being intellectually lazy to assume behaviour are there simply because someone is learning disabled. We currently work with around thirty clients per week, some of whom are referred to us for group therapy, and some for individual work.

The gender split at the moment is fairly even, as is the split between those whose experience of sexual trauma has led them to cause harm and damage to themselves, and those who cause harm and damage to others. We are a service that works with victims and perpetrators, and those who are both. As our service has developed, we have become more thoughtful about who we can work with - work can benefit from long term psychotherapy. Of course, this is all against the backdrop of a great deal of prejudice and misconceptions about whether people with learning disabilities can use psychotherapy at all - particularly psychoanalytic or psychodynamic psychotherapy.

One argument against using psychotherapy for people with learning disabilities is that it is an intellectual activity which those who are intellectually impaired would find impossible to use. My answer would be that we should rather be viewing psychotherapy as an emotional process which is not dependent on cognitive skills. In making an assessment for psychotherapy we will of course be looking at what the level of learning disability is - because this will help inform the treatment rather than mitigate against it. The assessment process involves not just the therapist and client - something which makes our service different form mainstream psychotherapy organisations who would view the involvement of others as antagonistic to the therapeutic process.

Experience has taught us that our work needs to be part of an inter agency approach - especially when the client is an alleged perpetrator of sexual abuse. We meet first with a member of the support team to find out more about the history of the client, what the experience of sexual abuse actually was, and the impact this has made upon the client's ability to function. We then meet with the client to find out what their understanding of psychotherapy is, and to explore how it may or may not benefit them. There are cases where we decide that psychotherapy is not appropriate. This may be based on the client feeling too fragile for such an intense process, or more on matters of safety - for example where we know that simply being in a room with another person may make the client act out aggressively. We will, through the assessment process, be examining the level of learning disability. With those clients who cannot talk, or who choose not to talk, we examine other ways they have of communicating.

Sometimes it may be through the use of dolls, or drawing, sometimes through the use of silence. The less able the client is to talk, the more our therapists rely on their counter transference, the feelings evoked within the room itself - which can often provide an powerful indicator of things which are unbearable to say. If one is feeling particularly sleepy, frightened, or eroticised within a session, it is important to examine these feelings in clinical supervision. Are they there because of external factors more to do with the therapist than with the client, or do they exist as a container for emotions coming form the client him or herself?

Psychotherapy with our clients needs to be long term, and can last between one and three years, sometimes more. Part of our job is to explain this as carefully as possible to commissioners of services who actually pay the bills, and who may be more used to treatments with are short term. I would say that one of the most important reasons for the long term nature of our work is that we are not simply working with the effects of sexual abuse. One of the first things I will seek to explore with a client is their understanding of why they have come to see me. The variety of answers has always been wide - "To learn more about money", "Travel training" and "Because my keyworker told me to," have featured fairly regularly. Sometimes clients are able to articulate more about the abuse they have suffered, and the devastation this has caused.

Once the therapeutic work has begun, we are often struck by how some clients spend much of their time in sessions exploring many other issues. One central issue has been the reality of living with a learning disability - something which is rarely spoken about with clients in their day to day lives. What we have learnt from our clients is that very early life experiences are not necessarily forgotten because one has a learning disability. Clients have talked about what it was like growing up knowing that there was an inherent difference between them and the rest of the world. The failure to reach milestones is a tragedy felt not only by the mother, but also by the child.

Relationships with non learning disabled siblings are often rooted in a painful mix of envy and longing. This dynamic can become entrenched in the child's functioning and exhibit itself through later relationships with peers and members of staff. We know that sexual abuse happens within the context of a relationship, and that fact can produce in our clients a deep confusion about the rights and wrongs of what they have experienced. This is in no way helped by the failure of the Criminal Justice System to treat victims of sexual abuse who have learning disabilities with the clarity we would hope for.

The majority of cases involving people with learning disabilities as victims of abuse do not reach the trial stage simply because people with learning disabilities are, on the whole, regarded as lacking the ability to be competent witnesses. This basic inequality can hamper the therapeutic process significantly, and has caused some of our clients to struggle with ever really knowing if anyone believes that they have been abused. Many of our clients have described emotionally barren lives in which their abuser provided something which was abusive, but also perversely rewarding. Clients have talked about their abusers being the only people who ever took the time to talk to them, or buy them nice things, or take them to nice places.

The constellation of supposed care and affection with erosion of body boundaries is a difficult one to unpack, and can appear deeply confusing to those working with or living with our clients. It is confusing to know that someone has sexually violated your child, and that your child is terrified that their abuser may get into trouble. It has been helpful in formulating therapeutic responses to sexual abuse to think about the effects of loss upon people with learning disabilities. The comparisons are many - death and loss for people with learning disabilities is something which have historically been difficult for services to consider.

To be sexually abused is to experience a devastating set of losses - loss of childhood, innocence, safety and, sometimes, loss of sense of self. We construct rituals around loss to help contain its chaotic effects - funerals, anniversaries, obituaries. When the sexual abuse of someone with a learning disability occurs the most common organisational response is one of understandable fear, which can, if left unchecked, become converted into organisational inertia.

Authorities are getting better at constructing policies and procedures on sexuality and abuse, but what often gets missed form them are the therapeutic needs of the client him or herself. Once the client has disclosed they have been sexually abused, who is then there for them to help deal with the emotional fallout? The loss evoked by the abuse will need, on some level, to be properly mourned if the client is to have a chance to understand the experience further, and to understand the defences they may have constructed to help deal with it.

For psychotherapy with people with learning disabilities to be effective we must consider it as part of an overall process in which other professionals will need to be involved. Gone are the days when Respond would take on a client without the guarantee of an effective support system being in place. Psychotherapy, by definition, will explore the defences the client has erected against the reality of the trauma they have suffered.

It will seek to gently dismantle those dysfunctional defences in favour of internal strategies which will enable the client to function more healthily. Even when the work is closely monitored through clinical supervision, the therapeutic process can feel chaotic to the client, and their responses to trauma may get much worse for a time. Which is why we say to referrers and support teams - things may seem to get worse before they seem to get better.

It is essential that workers and families are prepared for this, not least of all because of the temptation there may be to remove the client form psychotherapy when he or she becomes more depressed or more angry. We need to be warning people that this may well happen, and, however hard it may be, it is important to view this as something that needs to happen - something which may actually be "good" therapeutic progress.

We are in the middle of conducting a piece of research on the effects of our work over the past three years. Research into psychotherapy is notoriously difficult to do, as it involves looking at a process which is primarily an internal one. To help answer some questions we have engaged a Clinical Psychologist to construct a questionnaire which has gone to all of our clients and their workers and which seeks to answer questions such as: what was the emotional state of the client before during and after therapy? What were the difficult behaviours before therapy started and what are they like now? Has therapy helped?

This is very much a work in progress, and we will be publishing the full results in the new year, but so far the results indicate that, for the majority of our clients, psychotherapy achieved its aims. Clients are able to manage their behaviour better. They are able to think about what happened to them in ways which are not chaotic and re-traumatising. Relationships seem easier to deal with. The important thing to hold on to is that, while psychotherapy has been central to this process, it was not the only component, and much of our work has been with teams and families to help them think more about how to work with difficult behaviours, how best to support their clients in the home and in the community.

An interesting observation we have made form the preliminary results of the research is that when we look specifically at challenging behaviours exhibited by our clients, in the majority of cases these have lessened throughout therapy. In very few cases, however, they have lessened dramatically. It is usually a shift from one box (extreme challenging) to the next box (not so challenging). There are few instances where the challenging behaviour has gone completely, which may indicate the need for longer term work, or, once psychotherapy has come to an end, for the therapeutic input to continue in a less direct - through supervision of workers or regular sessions for the family to ensure the place to think about their child is an on going one.

Because of the constraints of time, it has not been possible to talk at any great length about actual case examples from Respond. Our sense from our work is that there are many prejudices which still need to be countered before the rights of people with learning disabilities are at least some way towards being equal to those of the rest of society. Our awareness of the vulnerability of people with learning disabilities needs to be heightened. Behind every headline grabbing scandal such as the Buckinghamshire case, there are hundreds of other smaller scale but just as devastating examples of abuse within settings charged with the care of people with learning disabilities.

We need to work towards the enshrinment of equal rights for learning disabled victims of sexual abuse in the eyes of the law. And, finally, we need to keep the therapeutic needs of victims and perpetrators of abuse who have learning disabilities uppermost in our minds when things about our own work practice, be we nurses, doctors, social workers, probation officers, whoever. Because people's cognitive skills are impaired does not entail that their ability to benefit from a therapeutic process is also impaired. The therapeutic works needs to be different - have slightly different boundaries, be slower, more geared towards non verbal ways of communicating. But it can still have an enormous effect upon victims of abuse whose needs are all important.