Finding a voice

For those who have been victims of childhood sexual abuse, there can be so many obstacles to creating an authentic life. The life paths taken in childhood may have set these individuals up for vulnerability or silence. If they spoke out and received resources, being removed from an abusive household could have led them to placement in the foster care system. This system has problems of abuse of its own. If they ran away and tried to make it alone, they could have faced homelessness and exposure to other forms of violence and addiction. And those who stayed and endured learned that their pain did not matter.

All of these situations are excellent for an abuser. It allows them to escape harsher penalties for their actions. A voiceless person on the margins of society is perfectly placed for an abuser to continue living their lives as if nothing happened. Or, at least, these abusers can create a narrative about their victim that exploits the vulnerabilities that everyone else can objectively observe.

The individuals who have faced childhood sexual abuse have a huge uphill battle. As OTs, it is likely we will be confronted with this mountain in our practice. Many health care providers have never been taught how to constructively address abuse situations except to say that they should report. However, the providers themselves are faced with the feeling that we must offer proof. There is always doubt that can be placed in their minds, potentially by the abusers themselves, who may still have authority over the child at the time of disclosures. If a provider has never experienced victimization, the trauma of the disclosure can send them into a form of secondary traumatization. This means the story itself leads to reactions and symptoms not unlike those of a person who has experienced the trauma themselves. Certainly, some experiences that are recounted require processing, emotional detachment, therapeutic skills to support, and resources to ensure adequate follow-up for the victim.

Some services that are supposed to handle these cases are woefully inadequate. Many may advocate for victims, tell them to report, and then judge the story for credibility. Instead of being heard, victims are often silenced after disclosure. The pressure they experience to give up on judicial processes is enormous. Those people assigned to help them often (perhaps unknowingly) discourage them from continuing because of the amount of work it presents. Certainly, these organizations are often charged with the need to build a case while simultaneously saying they are not offering any legal advice. In the process, there are tremendous emotional burdens that can emerge. Meanwhile, the legal system demands composure. Mental health and mental illness are weaponized to prevent the completion of complaint processes or stop victims in their tracks. It can certainly feel like the system is actually meant for the abuser.

I want all healthcare providers to understand that they still have a unique position to support victims. For those clients who dare to speak their story, we can address a process within our scope to support them. This could be a report to the police. Or a regulatory body where there have been abuses of power by our colleagues. This could be tip lines that allow us to report anonymously. Including our clients in these processes can allow them to see the work we are performing on their behalf. It can be a therapeutic activity to see that task taken off the shoulders of our clients as we support their disclosure. In some cases, we have the resources to refer to other professionals who deal with these situations with more skill and a specific professional scope to tackle the problem, such as social workers. Some clients would prefer not to disclose to multiple providers. In this case, we can still listen, document, initiate complaint processes with our clients, and offer continued support on their journey towards justice. If you wonder about the therapeutic value of this experience, remember what this kind of support can offer:

• A complaint can be a corrective action that allows a person to align with their values and goals.

• Systemic barriers are preventing our clients from meaningfully engaging in their environments due to decreased trust in others, poor self-worth, and decreased sense of autonomy, as sexual abuse often creates a trauma bond that is difficult to escape.

• Meaningful interactions with institutions, supported by someone with authority — like a health care provider — can add credibility and show that the client is receiving the mental health supports they need.

• Traumatic events fragment the self and the narrative. A clearer narrative and timeline, developed in the safety of a therapeutic relationship, allows those who take reports to understand what happened. This prevents dismissive actions from being taken due to a lack of a cohesive or linear narrative.

• Advocacy for our clients is a tenet of Occupational Therapy practice. We can feel the discomfort of the friction with those who disagree with our actions, but we must move past it to address our client's needs.

• Our assessments of cognition and mental health can allow for improved support, recognition of the harms caused by the abuse, and adaptations to the process the client needs to fully pursue justice.

Our awareness of what is taking place in our world and communities is vital to detecting which of our clients require our support and guidance. Violence, especially domestic violence in families and intimate relationships, often is a sign of abuse and neglect that has gone on far longer than one reported criminal act. Be mindful of the supports that exist to ensure collaborations and referrals that are productive. Not every organization is well-equipped to support victims, even if they claim it is their mandate. Following up with our clients about their experiences reaching out for support is as important as the support offered during the initial disclosure. We can help close gaps in services in ways that would be difficult for our clients on their own.

I often bring up how our work catalyzes change. Our actions must roll with the punches and keep processes for our clients moving forward. Make sure that the client's voice is never silenced again.