Sometimes psychotherapists have to learn a lot suddenly, even after many years in private practice. The third week of January 2004 was such a week for me. Three patients, who had been sexually abused, took actions that reinforced what I suspected about sexual abuse victims, and their family's and society's reactions to their abuse. During the same week, the personal experiences of a colleague, also sexually abused, added the final touch. Family's response of disbelief and rejection, in each case, created a second trauma resulting in rage turned inward for each patient. This result suggests that the psychotherapist has a special responsibility to understand, warn, and then validate the patient in preparation for this likely second trauma.

During this same week, the Psychotherapy Networker (January /February 2004) article by Bessel van der Kolk entitled In the Eye of the Storm arrived in the mail and once again helped me out. I learned why sexual abuse victims are very easy to dismiss or abuse again. They have a hard time protecting themselves from further abuse for two reasons. They were put into a traumatic situation where escape was impossible. Their body may have been frozen in time with an active response that could not be completed. Therefore, when the stress level gets high, they may again feel the same kind of physical freeze. Secondly, the traumatic event is stored in the lower parts of the brain (limbic system) and is not easily transferred to the frontal lobes where speech and reason take place. Therefore it is often very difficult for the victim to articulate what happened in a believable way. This is especially true if the abuse occurred before the time of language development. Therefore, in the real world, they look like easy pushovers. Someone can say, "I don't believe you." The victims do not know how to fight back to defend themselves. In the last analysis, without support for the patient from a psychologically sophisticated knowledgeable outside party, the perpetrators, who are used to deception, easily win once again.

It appears that the secondary disregard of sexual abuse from family appears almost as damaging as the abuse itself. It is one thing to have something bad happen sexually. It is another to have the perpetrator a family member. When there is no one else in the family to understand or take appropriate action at the moment or in the future, the rage, disappointment and devastation may get turned outwards towards others who are like the perpetrator and/or inwards to become serious suicidal risk.

I have always been validating and supportive of patients who have been sexually abused. Most of my past adult patients who have been sexually abused have never told their families because their intuitions told them clearly that there would be no support. The patients who have other family members currently at risk for sexual abuse are generally the ones who are forced, by the laws of mandatory reporting, to share these details with family.

I have learned that it is essential for us to tell our patients that sexual abuse appears too difficult for the vast majority of family members and society to contemplate or imagine; let alone live through. Once the patient understands this important information, they can avoid feeling traumatized once again, and can get back on their feet to finish their own work on this issue and go on with life.

It is now understood that Freud believed his female patients when they explained that they had been sexually abused. However, he sensed that society was unable to hear this information. He therefore minimized what he revealed to society by using the label ãHysterical Personalityä. How far has society come in being able to accept sexual abuse now? The evidence suggests that we still have a very long way to go. In the meantime, appropriate therapeutic support, in place of family, can be life saving. In summary, I can now answer three questions with renewed clarity.

1. How does the victim respond?
There are some common responses that are characteristic of most victims. If the abuse occurred before the age of six, there may well be confusion as to the identity of the perpetrator.

Victims are often confused about what it means to tell the truth because the perpetrator has taught them to lie. Most victims fervently hope that what happened was not really abuse or that they are remembering something that actually did not happen. They worry excessively about misrepresenting themselves or their perpetrators. Some victims experience a somatic response as the body's way of communicating that the abuse really happened. This pain can be every bit as painful as the original encounter. We have seen the longing to be believed and understood by family and the power that therapeutic understanding and even minimal family support brings to return victims to fuller functioning.

Under pressure, the victim can dissociate because that is the coping behavior they learned while the abuse was taking place. They feel worse than a "dirty dishrag" because they were abused. Since a perpetrator tends to look "through" them rather than "at" them while the abuse is happening, victims tend to feel that their existence and feelings are completely unimportant. In addition, the immature child's brain views grownups as all powerful and perfect,leaving the child feeling totally to blame.

There is hurt and rage when the family members support the persecutor and deny the victim equal rights. There can be confusion about enjoying or hating sexual relations, especially if their current sexual partner does something that reminds them of the former abuse, even if it is gentle and kind. Victims can impulsively reach out for compensation, legally or illegally. Rage can turn inwards as suicidal ideation.

2. How does family and society respond to a sexually abused victim who tries to address what happened in the past?
Perpetrators deny, disappear and quietly go on acting like perpetrators. Someone who is falsely accused, in marked contrast, tends to engage easily and responds with compassion, concern, sadness, and caring. They stick with the issue until resolution is achieved.

Sexually abusive behavior appears to be so unacceptable that some family members prefer to immediately reject it. They seem incapable of considering that it might have happened and imagining what it must have been like. Some knew that the abuse was happening at the time but systematically ignored the signals. Sometimes, they are completely unable to respond to this shocking information. It is therefore predictable that they should defend by turning a blind eye. It is far easier to respond with hostility, rejection and direct punishment while the victim is too immobilized to resist. Silence from a family member may mean that person has also been sexually abused. The victim faces new trauma by this kind of family response and is, once again, devastated by the dismissal of information and lack of support.

3. What are the therapist's responsibilities?
It is imperative to avoid new trauma from the family's defensive hostility whenever possible. The therapist must provide the belief, respect and support that are missing from the family. It is generally easy to believe the patient because the details they provide of the sexual abuse are too unpleasant and unique to make up.

It is important to consider very carefully with the patient whether to tell the family: if the statue of limitations has expired, there may be reason to believe that the abuse is not continuing with any other victim. The therapist and the patient must weigh carefully the advantages and disadvantages of revealing the abuse to the family. The patient's opinion is very important since the patient knows the family members better than the therapist.

If the case requires mandatory reporting, the patient needs to be informed ahead of time that the family is not likely to be responsive in a positive way. The family's behavior does not mean that the patient is bad or is lying. The patient needs a clear explanation that s/he is never to blame for the abuse or the reporting because the victim's immature underdeveloped childhood brain can only misconceive that it was the child's fault.

If the abuse is confronted, or the abuse is reported to Child Protective Services, the therapist has to be available to help the family through their defenses to their own underlying horrified feelings. Revealing abuse always constitutes a family crisis. This is often difficult, if not impossible, when the family doesn't want to be involved or lives far away. Therefore the decision to report is often fraught with deep conflict for the therapist.

The therapist needs to be available on a long-term basis to help the family or effectively refer the family to another therapist. Families of my patients need the information about psychological and physical reactions to abuse so that the family can stop viewing the victimâs minimal response as "incompetence" or "lying." The goal in such long-term work is to help any family member willing to believe the victim, and to understand that their support is critical in the healing process. We can actively celebrate and compliment any family member who is able to understand and be supportive.

We can also help families, inasmuch as possible, not to fragment by taking sides and rejecting one other. This is especially important for family events such as holidays, decade birthdays, births, weddings, anniversaries, and funerals. The July/August 2003 Psychotherapy Network has a specific article on how to bring a family disrupted by sexual abuse allegations together for weddings and funerals without fragmenting further by arguing about the abuse.

The therapist can always hold onto the hope that the family will, in time, come to a more understanding position. To promote this, the therapist's door needs to remain open.

Dr. McArthur is a psychotherapist in practice in Los Angeles. She is the president of the Independent Psychotherapy Network.

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