My client has regular contact with an elderly family member who systematically abused her as a child. Should I still offer her trauma-focused therapy?
There are complex issues to balance here, some of which your client may not have thought about, or may be actively avoiding. One school of thought is that spending any time around a perpetrator will be actively harmful and potentially re-traumatising, and therefore she can never really hope to recover from her PTSD as long as she maintains the contact. At the same time, if your patient has PTSD and is seeking treatment, then as much as possible it is important that you work to overcome treatment barriers with her, and to maximise her control over the therapy decision-making process.
Firstly, you need to explore together the actual risks that the now elderly perpetrator poses. Explain that establishing her safety and that of others, including any children, must be your shared primary priority. Be explicit and transparent about the limits of confidentiality around any disclosures she makes, and before asking her any detailed questions. Then ask if there has been any recent or ongoing physical, verbal, sexual, financial or emotional abuse in the context of the contacts. Gather details of what, when, where etc. and follow your local safeguarding policies. Develop a safety plan with your client to help her manage the risks of contact, and then make sure to review it with her each week.
If there are no apparent current risks, or if they can be effectively managed with a safety plan, then it should be your client’s decision whether they want to continue that contact while having treatment. They may not feel ready or able to end the contact with the perpetrator, even if it exacerbates their PTSD symptoms. Indeed their PTSD symptoms may be exerting a strong influence on their ability to take assertive action or make a decision to end contact. So it might be that treating their PTSD helps them to think more clearly about their needs, and what contact they want in the future.
Even if your client is not ready or willing to end the contact, it might be helpful to talk through with her the costs and benefits of maintaining the relationship, including weighing up any potential impact on the process of therapy. Often this will help the client to better understand the competing pressures and needs that might lead her to maintain contact with the perpetrator – whether it be a sense of loyalty to the perpetrator, pressures from other family members, a fear of being rejected or exiled from the family, a fear of the consequences of confronting the abuser or exposing the truth, or simply that they don’t know what else to do.
Working on the trauma memories may be important, if not essential, to helping your client come to a point where they can choose to stop seeing that family member. At the moment they may feel too intimidated, helpless or trapped by a sense of loyalty or attachment originating in unmet childhood needs. They may struggle with very hard-wired ‘surrender’, ‘shutdown’ or ‘appeasement’ coping, that kicks in automatically when they are around the perpetrator, making it really hard for them to think straight or take action.
So, in some ways it may actually be the other way around – they may need to work on trauma memories to fully appreciate the harm they have experienced, and feel empowered to make a change. Only then can they decide what they want or need to do, be it confront, contain or distance from the perpetrator.
Processing the childhood trauma memories can also sometimes help update your client's perceptions of the perpetrator as they are now – PTSD re-experiencing symptoms will make the perpetrator still seem all-powerful and terrifying, while they feel as vulnerable and helpless as when they were a child. Updating these memories can help your client realise they now have more control and agency, and that the perpetrator is now weaker, less powerful and no longer a threat (if this is indeed the case). They may also come to see them as pathetic and damaged rather than omnipotent. Updating childhood trauma memories can also help your client think in a more ‘healthy adult’ mode about the terms of that relationship, and what they want from it once they have recovered from PTSD.
Instead of a safety plan, another good option might be to agree a temporary break from seeing the abusive family member for the duration of the treatment, so your client has the necessary psychological space to process trauma memories without being complicated by ongoing reactivation. Your client might need to develop a ‘cover story’, such as having an infectious illness, that gives them permission to absent themselves from family gatherings temporarily. Bear in mind that, as emotions like fear and shame recede during trauma processing work, other emotions like anger and sadness may come to the surface. Helping your client think through how they want to express those emotions will then be important.
Another possibility can be to develop a plan whereby they can maintain contact with the perpetrator, but minimise interactions with them or change how they manage that relationship, for example, only speaking to them on the phone, or having emails automatically go into a separate folder so they choose when to read them. If they are worried that breaking contact with the perpetrator would mean losing touch with other family members, again this can be problem-solved and tested, as there may be alternative ways to maintain these relationships without being around the perpetrator.
At some point your client may decide they want to disclose their abuse experiences to family members. We always encourage our clients not to feel hurried into making decisions about disclosure, nor that there is a one-size-fits-all rule about needing to disclose. Often it can help to write out a pros and cons list, and plan for the full range of possible outcomes from best to worst. They may need support in deciding what to disclose, to whom, and in what setting or format.
Bear in mind that other family members may have been complicit, bystanders, victims or involved in other ways in the abuse too, so the decision to ‘go public’ can bring its own challenges from others’ reactions. This is why it is important to remember the golden rule of "hope for the best but plan for the worst" when supporting your client to take step towards making disclosures.
Key practice points
· Assess any current risk from the perpetrator
· If the client is at risk, follow safeguarding procedures and work on a safety plan
· If the client is not at risk, trauma-focused work should still be possible, prioritising trigger discrimination and updating trauma memories
· Help your client consider the costs and benefits of maintaining a relationship with their abuser; this may change as they progress in treatment and recover from PTSD