Ethical Issues in Counseling Adult Survivors of Sexual Abuse

An adult survivor of childhood sexual abuse who seeks counseling is going to demand more of a counselor than an adult who did not encounter that kind of trauma as a child. These patients have been described as "the most needy, vulnerable, and traumatized of all psychotherapy patients" (Knapp & VandeCreek, p. 452, 1996). Early studies have shown that as much as 30% to 33% of clinical populations have been victims of childhood sexual abuse (Daniluk & Haverkamp, 1993). With that being said, "a history of childhood sexual victimization is implicated for many adults seeking counseling assistance" (Daniluk & Haverkamp, p. 16, 1993). It is inevitable that a counselor is going to be working with someone who has a history of childhood sexual abuse. Therefore, it is important for counselors to realize that there are special ethical considerations that need to be considered when counseling an adult survivor.

The effects of childhood sexual abuse are emotional, psychological, and relational. The term sexual abuse survivors syndrome has been used "to describe the post-traumatic stress-like symptoms that often accompany a history of childhood sexual victimization" (Daniluk & Haverkamp, p. 16, 1993). While young boys are victims of sexual childhood abuse, the majority of cases involve female children that were abused by an adult male (Daniluk & Haverkamp, 1993). To begin, it is important for a counselor to gauge the appropriateness of their intervention. For example, an aggressive or confrontational type of therapy would more than likely not be the best approach for a childhood sexual abuse survivor. It is also important for the counselor to have competence in the area of childhood abuse. "Protecting the client against incompetence and unwarranted risks is critical to all ethical practice but takes on additional importance in work with sexual abuse survivors. Survivors characteristically experience difficulties with trust and vulnerability in their adult relationships based on their early experiences of profound betrayal" (Daniluk & Haverkamp, p. 17, 1993). Once the counselor has chosen the appropriate therapy, there are still other ethical decisions that need to be made.

It is almost impossible to have a discussion about adult survivors without the mention of repressed memories. Repressed memories form because survivors have "protected themselves from psychological disintegration through repression of memories and emotional dissociation" (Daniluk & Haverkamp, p. 18, 1993). Though repressed memories may be inherent to adult survivors, mental health professionals are "becoming reluctant to treat adult survivors of child abuse because of fear of litigation from patients or their parents who claim that [they] implanted false memories of childhood abuse" (Knapp & VandeCreek, p. 452, 1996). It is clear that there are greater liability risks when dealing with an adult survivor who has repressed memories compared to a survivor who has always known or whose memory of the abuse appeared spontaneously on its own. The liability risk is higher if the client "retrieves memories through talk therapy and the psychotherapist has documented the content and nature of the treatment sessions" and the risk is highest when the psychotherapist "uses experimental techniques to retrieve memories" (Knapp & VandeCreek, p. 452, 1996). There is some debate as to whether recollection of the memories is essential or helpful for treatment and how and when this should be addressed in the therapeutic process. There is no concrete answer to this question and it is left up to the discretion of the counselor and the client with the core idea being not to cause harm to the client. "Manipulation or forced recollection would constitute a violation of client autonomy" (Daniluk & Haverkamp, p. 18, 1993). It is important to maintain/foster autonomy in all therapeutic relationships, but this is even more the case with adult survivors as "they have experienced severe breaches in control over their lives and bodies" (Daniluk & Haverkamp, p. 18, 1993). Therefore, it is important for the client to choose when they want to explore the past abuse and at what speed. It is also imperative for the counselor to discuss the risks and benefits of exploring the memories as well as all treatments that will be used. Legal risks can be reduced if the counselor maintains appropriate boundaries, uses care when providing a diagnosis, uses sound clinical techniques that are based on scientific knowledge, obtains informed consent, and shows concern for the client's future relationships with their families (Knapp & VandeCreek, 1993).

Working with adult survivors also brings up ethical issues regarding the survivor's relationship with the abuser and the relationship with their family. When counseling an adult survivor the following ethical dilemmas must be addressed: "confrontation, action against the abuser in the forms of reporting and filing charges, maintaining or severing contact with the abuser, and restitution" (Daniluk & Haverkamp, p. 18, 1993). Because childhood sexual abuse is rooted in secrecy, breaking the silence is an important part of the therapeutic process. It should be the decision of the client to confront the abuser, but the counselor has to always remain supportive and explain the risks and benefits of the confrontation. One of the possible risks involves being called for trial if legal action is taken. Not only will the client have to deal with painful memories in court, but the counselor may be called to be a witness, which would cause the limits to confidentiality to take effect and may damage the client-counselor relationship. Other ethical issues to be considered are if the abuser has contact with children and laws regarding restitution. As all clients have families, there are also ethical considerations that concern the survivor's family. As the client works through the abuse in therapy, they will be faced with the decision to disclose the abuse to family members. There are also ethical issues to deal with if the abuse is uncovered during couples counseling. If this is the case then a new therapeutic contract may be necessary or a referral for either the survivor or the spouse may be more appropriate. Other relationships that are important are her children as well as other close relationships.

It is true that working with an adult survivor of childhood sexual abuse can be demanding on a counselor. The ethical principles, such as beneficence and nonmaleficence, are especially important when working with this population. If a counselor does not feel that they can provide the best services for an adult survivor, they should immediately refer them to another professional who can better help them. If the counselor is unable to find help for the client, they should not turn them away, but should continue to support them until proper help can be found as well as make the client aware of the situation. Trying to help an adult survivor without having the correct skills and tools will undoubtedly do more harm than good and may put the counselor in a difficult position if faced with an ethics charge. There are many difficult and painful choices that need to be made for both the counselor and the client. It is important for counselors to follow the guidelines I have listed above, consult the ethics standards of their profession, and ask for supervision and seek the advice of peers if necessary. Overall, the counselor must remember that the client has enlisted their help and should be given the best care that the counselor can provide.

References

Daniluk, J.C. & Haverkamp, B.E. (1993). Ethical issues in counseling adult survivors of

incest. Journal of Counseling & Development, 72, 16-22.

Knapp, S. & VandeCreek, L. (1996). Risk management for psychologists: Treating

patients who recover lost memories of childhood abuse. Professional Psychology:

Research and Practice, 27, 452-459.