Sexual Abuse – A Relational & Somatic Approach to Recovery
As a trauma therapist, I work 100% with relational trauma. I would estimate that approximately 90% of cases involve physical or emotional abuse. Half of these cases involve some kind of sexual abuse. Sexual violation ranges from inappropriate patting and touching between siblings and cousins, through to penetrative incest, rape by a family friend or other authority figure like a teacher, through to experiences later in life involving violent rape and gangbanging. I have seen cases at every level of severity.
I believe that sexual abuse is the most heinous violation of the human body. It extends its savage tentacles not only into the psyche, but into the spirit of its victims, leaving them forever changed.
I don’t know if therapy can ever completely heal us from these kind of experiences, but I do believe it can go a long way to repairing the psychological and somatic damage as well as nourish the wounded spirit.
The effects of sexual abuse are severe and complex. As such, it makes sense that the therapeutic approach to repair requires nuance, skill and an incredible gentleness. The sexual abuse victim has a high propensity for re-traumatization, and often goes through life experiencing simple relational interactions as mini reoccurrence’s of violation.
Relationship is a potential source of great harm.
Relationship is also a potential source of great healing.
This is one of the first things I explain to my clients who walk through the door at Soma Clinic.
In the last year, I have been placing a lot of effort in raising awareness about the relational and somatic approach to trauma recovery. Nowhere (until now), have I shared anything specifically about sexual abuse. Recently, we have started to receive a large volume of new clients seeking somatic therapy who indicate a history of sexual abuse. In fact, every single new client arriving via Google and Instagram, has this in common. Watching this wave of survivors stepping up with courage and vulnerability to ask for help, has inspired me to start sharing more on this topic, as well as begin to educate other practitioners on my approach to recovery from sexual abuse. In this article, I hope to illuminate some of the symptoms and existential experiences that a sexual abuse victim may experience, as well as share therapeutic concepts to approach recovery and reclamation.
Sexual abuse indicators
Below I have outlined some of the ways that sexual trauma may present. Every client is different, and may present with either a handful or a huge array of indicators. As a therapist, knowing what to look out for, not only in the client’s story, but in their physical and relational presentation, can be helpful for mapping out a treatment plan. While talk therapy is an essential part of care, because the abuse was a very physical experience, working with the body is essential to integrated healing. This is why approaches that blend both talk and touch may be most helpful when it comes to sexual abuse recovery.
Emotional
Body shame/dysmorphia and/or eating disorders
Feelings of shame, worthlessness and powerlessness (that present through their engagement with the world)
Fragmentation/Inner conflict — 2 or more voices in head, making it hard to make decisions, or regular self-shaming
Emotional outbursts (usually anger)
Low libido OR Promiscuity
Anxiety
Nightmares
Hair-pulling, nail-biting, scratching, ticks/twitches
Relational
Inability to say no and set boundaries
Intense Feelings of physical violation, when there is no violation (e.g. someone stands too close, personal space is taken away by work, family kids, triggered by expressions of aggression)
Dislikes being cuddled
Protective of abdomen (touching the stomach sends them into a threat response)
Hyper-vigilant towards the presence of other people
Does not like to be touched at all (gives them the creepy crawlies or feelings of repulsion)
Feeling disgusted by other people regularly
Feelings of misconnection (can’t quite make an authentic connection, even though there are close relationships)
Physical
Nausea
Vaginismus/painful sex
Bracing of the ribcage and intercostal muscles
Rigidity of the spine and hips
Tightness in the pelvis and hip muscles
Fascial back line constriction
Constriction of the diaphragm, reducing breath capacity
Digestive issues (may range from constipation through to loose stools, or indigestion and inability to metabolise iron and certain nutrients)
A Relational Approach and Psycho-education
Because sexual abuse is a gross, relational violation, a safe relationship must be established before recovery work can begin. At the onset of therapy, it is important, not only to attune to the client, but to psycho-educate and illuminate the links (as listed above) to their abuse story. Helping the client to make sense of their ‘why’, provides an immediate release of shame and cultivates a high level of attunement. They are finally feel seen, heard, understood and safe; feelings they perhaps have not truly felt since before the abuse.
Often, a client will have never shared their abuse story to anyone before. In order to reach out and ask for help and start sharing, they will have had to overcome a number of layers of fear and shame. They are vulnerable as soon as they make contact. Treating this vulnerability with extreme gentleness is really important. First and foremost, the client needs to know that their story is safe with you, that they will not be judged, and that their expression and emotions are welcome. If you are working with the body, they need to know that they physiological impulses/expressions are also welcome. In the case of any kind of physical abuse, the victim does not get the chance to say no, scream, growl, shake, kick, push or run. In most cases, the victim will freeze and disassociate in order to survive. These unexpressed impulses become locked inside them and they spend a life building protective mechanisms to keep them quiet and find a way to survive and thrive in the world. In the case of adults who have survived childhood sexual abuse, there are layers and layers of the constructed self that are at play. While my approach does not seek to regress the client or to ‘relive’ any experiences, it does support the client to allow the body and the voice to discharge any impulses/responses that are either live or dormant inside them, waiting for a chance to express. Here, it is important to note, that most people end up at our clinic because the trauma has been triggered and is ‘live’ in their system. That is, their experience has been hijacked by the past experience that they can no longer suppress. The experience is in line with PTSD/CPTSD, but usually undiagnosed.
At the onset of therapy, it is also important to provide a map for treatment and gain consent from the client. The fear of what may emerge during the therapeutic process can hinder the readiness to fully engage with it. Explaining the approach to care is important for allowing the client to take your metaphorical hand and walk into the dark woods with you. Once the client chooses to process with you, there is already a relational healing. They have made an empowered choice, which is something they could not do in relation to their abuser.
Working in Layers
Our brains and bodies are very clever at protecting us. When there is an experience that is too overwhelming to process, we suppress it, in order to continue ‘going on with life’. To face and feel the experience would be too horrifying. Because of the intensity and complexity of the abuse, it can be helpful to process the trauma in layers. This falls in line with a trauma-informed approach, with intent not to re-traumatize. In order to successfully do this as a therapist, we must be confident with our story navigation skills, as well as our ability to resource, and manage activation with titration and pendulation. Depending on the severity of the case, recovery may happen over as few as 4–6 sessions, or as long as a year. This really depends on a) the client’s capacity/readiness to process b) the complexity of the trauma c) your skill as a therapist.
To start with, I invite the client to tell me their story.
Meeting the client where they are
The way a client tells their abuse story informs how much capacity there is for physical and emotional processing. I will be watching to see how their body responds and their ability or inability to make eye contact as they talk, whether they access emotion or talk in a dead-pan voice about the most horrific experience. I will note if they rush through or skip parts of the story, or minimize the experience (knowing that at some point we will need to circle back to these aspects). If the client is not able to access emotion and connection while telling the story, it signals the experience is too overwhelming and that the emotions connected to the experience are not containable. I will always bring this resistance to light with the client. I will re-iterate that the approach is to work gently and slowly. This serves to highlight their experience of relational safety. There can be a huge fear that if they access the truth of the abuse story, that they will drown in it. By meeting the client where they are, attunement deepens and work can begin. This level of attunement itself can invite a surge of relief and grief. This may look like tears, ‘collapsing’ of the torso or gentle shaking. Again, bringing cognitive awareness to this experience is helpful because the client likely does not have enough capacity to make sense of it. At this point, they are attuned enough to begin working with the body.
Consent, Permission, Conversation, Choice
In the world of somatic psychotherapy, there are big warnings against re-traumatization. This is because working with the body means we are working with the physiology that is holding the unprocessed threat responses. In order to work with the body, we need to be confident with our touch skills and our own somatic sensing process. The worst two things that could happen are: 1) to trigger the client, and be unable to support release and integration. 2) Failure to catch the client’s internal non-verbal fragmentation or regression and leave them trapped inside their trauma narrative.
One way to reduce the risk for re-traumatization, is to work with a permission-based approach to touch. When a client has had their physical boundaries breached by an abuser, it is possible that any form of physical contact may be received as a violation (even when the therapist and touch have been marked as safe). Seeking permission for every new touch can ensure that the client engages from a place of choice. The continued conversation also ensures that the client stays present and associated and does not fragment or regress. Something else to watch out for is when a client consents to touch, but the body braces/repels from it. This is an indication of mind-body split and part of the trauma response. At the time of the abuse, the body wouldn’t have been able to say ‘no’. This often leads to an inability to match the somatic ‘no’ impulses to the mental/verbal experience. Clients may be aware that they are just ‘baring with it’, or they may be completely unaware (which signals a deeper layer of dissociation and disconnection). Working on the treatment table, I am going to watch and feel for the somatic dissonance and bring gentle awareness to it. The intention of this process is to help the client connect to their somatic ‘no’ and follow their impulse to express it to me. When their integrated mind-body ‘no’ is received and responded to, they learn ‘it is ok to say no’ AND, ‘I am physically safe with this therapist and this process’.
Entire sessions can be done simply working with permission-based touch, working to integrate the mind-body ‘no’ and also the mind-body ‘yes’. The ‘yes’ part is just as important. When a client can identify touch as safe and welcome, and can both ask and happily receive, their relational and somatic experience is transforming.
Self-care note: For those clients in safe relationships, where touch has become difficult or triggering, I will often suggest self-care exercises where the partner seeks permission to touch, and invites the authentic response or yes or no. This self-care exercise has been incredibly bonding for clients and their partners, promoting the safety and trust required to re-establish vulnerability, and safety that leads to increased intimacy.
Physical Discharge
When the client has either overwhelming emotion or resistance to feeling emotion, it can be helpful to work with promoting gentle physical discharge on the treatment table. Working only at the physical layer can feel much safer to a client who is worried about delving into their trauma story. On the table this can look like, twitching, shaking, local or full-body unwinding, stretching or curling up. Setting intention is very important to invite this kind of physical release, that does not transcend into the trauma narrative. The goal is to promote relational safety and also watch out for signs of activation, and use direct verbal cues to support the session to stay only on the physical layer. This doesn’t mean that the client wont cry — they may. They may also yawn, cough or laugh. The important difference is that they are staying present in the body on the table with a very physical process, knowing that it is part of an intentional plan to help them recover and reclaim themselves.
For some clients, one session like this may be sufficient. For others, a few may be required. This depends on the intensity of their emotional overwhelm or disconnection. Once a client has discharged enough safely, there will be a natural readiness to start talking about the experience with more authenticity and palpable but containable emotions.
Self-care note: If I feel that a client is safe enough in their experience of physical discharge (that is there is no tendency to regress or over-activate), I will suggest that they replicate the experience at home on a yoga mat. This can be helpful for both propelling the process forward, and self-managing mild triggers. I will always equip them with techniques to ground and integrate at the end of their practice. Ultimately, they are empowered to take control of their own healing, which ignites another relational repair.
Emotional Processing
Once the client has enough capacity to naturally start connecting to the emotions associated with the abuse story, emotional processing and integration can begin. While each client is different, there are a number of emotions to look out for during the arc of treatment.
Blocker Emotions — Fear and Shame.
In order to reach some of the more complex and difficult emotions, fear and shame need to be accessed first.
Fear
Fear is the usually the most readily-accessible emotion. For most, the experience of abuse was terrifying. The gentlest way to process fear, is to promote feelings of safety in the present, letting the client’s body know that the experience is over and they are safe. When working with this somatically, the client is often laying under a weighted blanket (face up or side-lying), with heated pillows to nuzzle into. I invite the body to let go of the experience of fear. It is very simple, safe and effective. Safety is the antidote to danger.
Shame
In my experience, shame requires repeated addressing in relation to each layer of processing. Often the client is not only ashamed of the experience, but they are ashamed that the past experience is still effecting them in so many ways now. In addition to processing shame at the onset of therapy, I will keep an eye out for it lifting for expression at any point during processing. It is one of the most common resistances to processing.
The Trauma Triangle
Next, I work with what I call, ‘the trauma triangle’: Anger, Grief, Powerlessness.
The experience of being powerless against the abuser leads to feelings of both anger and grief, that have no path to express and integrate. Working with each of these is essential to healing. Usually, I will look for signals of these emotions through the talking component of therapy and make links to the somatic narrative. Once we have established how the suppressed emotions are living and breathing in the body, the client is ready to process them. It is important to work with one emotion at a time, to ensure a smooth process that culminates in integration.
After the table session, I will spend time with the client making sense of their experience and also explore how these suppressed emotions have been triggered in their lives. For real-life integration to occur, I invite the client to start becoming aware of their triggers, disrupting the reactive pattern and acknowledging the need to find a pathway for discharge and internal safety. Here, the client is empowered to start a) expressing themselves b) re-parenting themselves. Once a client is able to self-manage their triggers, they are no longer controlled by the past abuse. The element of powerless no longer looms within them, which in turn leads to the natural integration of anger and grief.
Note: This part of therapy takes a cognitive approach. The difference between this and traditional cognitive based therapies (like CBT) is that the cognition comes after felt/somatic process. Left brain follows right brain. I have found that this makes all the difference because the client is having an integrated experience, rather than a purely rational one that bypasses their felt sense.
Disgust
Disgust is often associated to sexual abuse, because it is, indeed, disgusting. It is closely linked to anger, but has a very different signature. This can be one of the most difficult emotions to process, because it is repellant in nature. ‘Acting-In’ disgust is very common — that is the client experiences ‘self-disgust’. Exploring the connection to disgust and the abuse story promotes a process where the client can be encouraged to ‘act-it-out’. Somatically, disgust arises as feelings of nausea, bile rising, retching, gagging and sometimes spitting. As a therapist, working with disgust can feel very intense and it is more important than ever to be grounded and ‘somatically separate’ to the client. I have found that after processing disgust, clients feel an incredible sense of relief and spaciousness, that promotes a re-orientation to self-compassion and self-love that is authentic, rather than fake and forced.
Note: I often see clients pretending to be self-compassionate or loving, but on the inside still feeling self-disgust or self-hatred. Once the disgust is truly processed, the act of loving the self, can be real, rather than an attempt to remedy the disgust.
Emotional processing can be life-changing. Once the client is no longer controlled by their suppressed emotions and experiences, they are free to start living in the present. This commonly provides a gateway into great transformation. I have seen many clients make brave career choices, step out of harmful relationships and into great ones and start to create lives built on choice, freedom and desire.
Self-care
As mentioned briefly in some of the above sections, empowering the client to self-care is essential to real-life integration. Processing occurs in the treatment room, but healing occurs in daily life. Speaking with clients about this, enables them to take ownership over their self-reclamation. At the end of each session, I will equip my clients with new self-care tools that support their phase of recovery. These may range from breath practice, to somatic awareness to orientation exercises, to journaling on certain experiences, to working with triggers, or noticing and challenging their relationship dynamics. Here, there is a coaching element to therapy. Ultimately, I seek to empower to do it on their own, so that in the not too distant future, they can ‘fly the trauma therapy nest’ and happily look after themselves.
Summary
Sexual abuse is one of the most awful experiences to live through, and one of the most difficult experiences to work with as a therapist. In order to truly help our clients, we need to work gently, layer by layer, not only with the mental emotional experience or the physical experience, but in a way that honors the deeply existential shift that occurs as a result of such horrific violation.
If you are interested in learning more about a relational and somatic approach to trauma recovery, you can opt into the immersion training in Singapore
https://illumahealth.podia.com/trauma-informed-relational-somatics-online-workshop
or approach me for mentoring/supervision via email.