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Research Reports |
CL Schachter, PhD, PT, is Assistant Professor, School of Physical Therapy, University of Saskatchewan, 1121 College Dr, Saskatoon, Saskatchewan, Canada S7N 0W3 (schachter{at}sask.usask.ca).
CA Stalker, MSW, PhD, is Assistant Professor, Faculty of Social Work, Wilfrid Laurier University, Waterloo, Ontario, Canada
E Teram, PhD, is Associate Professor, Faculty of Social Work, Wilfrid Laurier University
Address all correspondence to Dr Schachter
Submitted December 18, 1997;
Accepted October 15, 1998
 | Abstract |
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Key Words: Childhood sexual abuse • Qualitative research • Sensitive physical therapy practice • Violence
| Introduction |
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 TopAbstract Introduction The StudyDynamics and Long-Term Sequelae...ConclusionsReferences |
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Researchers have repeatedly demonstrated that traumatic childhood experiences, including childhood sexual abuse, are associated with higher rates of lower back pain,6 chronic pelvic pain,7–9 gastrointestinal disorders,10 chronic headaches,11,12 and general medical problems.13,14 These findings reinforce our belief that physical therapists work, often unknowingly, with adult survivors of childhood sexual abuse.
| The Study |
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TopAbstractIntroductionThe StudyDynamics and Long-Term Sequelae...ConclusionsReferences |
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Female survivors were recruited through agencies, groups, and individuals providing counseling and support for survivors in Saskatoon, Saskatchewan, Canada, and in London, Guelph, Kitchener, and Waterloo, Ontario, Canada. Representatives of social service agencies or groups organized for survivor support were contacted about the study and were sent both a poster and a written description of the study. These individuals chose whether to display the poster, present the information to individual women, or both. Survivors who were interested in participating in the study contacted us.
In order to participate in this study, women were required to have either formal or informal support around issues of sexual abuse through, for example, counseling and self-help groups. We recognize the bias that may have been introduced by excluding those women who were not connected with some form of formal or informal support or those women who did not choose to volunteer. Nevertheless, we wanted to be able to refer participants to their counselors or support staff should they need to process the impact of the interviews.
Childhood sexual abuse is equally traumatizing to boys, and studies suggest that although there are differences, the short- and long-term effects on boys are in many ways similar to those on girls.16,17 We hope to conduct a similar study with male survivors in the future, but for this study, female survivors were chosen because research to date suggests that they are abused in greater numbers.1–5
The mean age of the participants was 39 years (SD=10, range=19–62). The majority of the participants (n=21) reported having a community college or university education. Four participants had a secondary school education, and 2 participants had a primary school education. Participants listed occupations as homemaker, librarian, life skills coach, minister, teacher, nurse, nurse's aid, receptionist, social worker, student, writer, and unemployed. One woman identified herself as Métis;
26 participants identified themselves as Caucasian.
Four participants had chosen not to see a physical therapist for their problem or condition. Seven participants had seen a physical therapist once. The remaining 16 participants had seen a physical therapist on more than one occasion for up to a maximum of 5 different types of treatment. The types of conditions for which physical therapy was sought were primarily musculoskeletal, carried out in outpatient, inpatient, and homebased settings, although participants had also seen physical therapists for cardiorespiratory conditions in home-based settings and inpatient facilities. No participants reported seeing physical therapists for neurological conditions. Conditions included asthma, fractures and sprains, back pain, headaches, neck pain, and total joint replacement.
Participants signed informed-consent forms and were offered $20 honoraria for their participation in interviews lasting approximately 60 minutes. Two of us (CLS and CAS) conducted the interviews, which were audiotaped and transcribed. Following the conventions of grounded-theory research,20,21 no attempt was made to predefine relevant data or to use predetermined questions. Thus, each interview was very different, as we concentrated on the issues raised by the participant. The focus of each interview, however, was on the emotions and concerns related to contact with physical therapists.
By use of the constant comparative method,20 the data analysis began when the data collection commenced and guided the ongoing interview process. Patterns emerging from the data were used to form a theory that encompassed survivors' experiences and ideas for sensitive practices. Using Folio Views 3.1 Infobase Management Software,
we each analyzed the data independently and then discussed the data as a group. Although there were variations in the labeling of some categories, there was a consensus after a brief discussion regarding the main emerging themes.
Our interpretation of the data was shared with the participants in an effort to ensure that it reflected their reality. Each participant received a summary of the interpretation of the data and was invited to respond. We obtained other evidence for the reliability of our analysis in the second phase of this study. Eight survivors who had been interviewed earlier met with us and 8 other physical therapists in a series of meetings to develop guidelines for what they believe is sensitive physical therapy practice. Survivors' feedback throughout this process appeared to confirm the centrality of the themes that we identified.
| Dynamics and Long-Term Sequelae of Childhood Sexual Abuse |
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TopAbstractIntroductionThe StudyDynamics and Long-Term Sequelae...ConclusionsReferences |
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When a child is abused, she feels out of control and disempowered. She is invalidated, because what she wants does not count. As a result, the child learns that her body does not belong to her and that she apparently has no right to say what happens to her body. She learns to disown and not care about her body. She may learn to disregard or ignore signals of pain, injury, alarm, danger, or pleasure that the body generates and may also disconnect from the body. Thus, the survivor's relationship or connection with her body can be damaged.22,23 Childhood sexual abuse is, by definition, a violation of boundaries. Most children learn about boundaries early in life through day-to-day interactions. They internalize ideas about what is personal or private and about what physical and emotional closeness and distance mean. When a child experiences that other people respect her boundaries and her wishes for privacy and separateness, the ideas that she is a person, separate from others, that she is a self, and that she has an identity of her own are built and reinforced. However, a child who is sexually abused is treated as though her body belongs to someone else. Her body is used to meet someone else's needs, and her feelings, wishes, and needs are not important. Thus, her relationship or connection to her sense of self and her sense of who she is is damaged.
Most sexual abuse is perpetrated by people known to the child—for example, family members, baby-sitters, friends of the family, teachers, and clergy members—people given responsibility for protecting and nurturing the child. The lesson from this experience can be profoundly damaging. When such people take advantage of her, the child feels betrayed. The world becomes an unsafe place as the child learns that people who say that they care or are in caretaking roles cannot be trusted. Thus, her relationships with others are damaged.22,23
The aftereffects of childhood sexual abuse range from apparently no or minimal effects to severe impairment that affects almost every aspect of the person's life.24,25 For many survivors, the severity of the long-term effects has been shown to be associated with the relationship to the perpetrator, the intrusiveness of the abuse, and the use of force, but many factors, such as age at onset of the abuse, duration of the abuse, and supportiveness of families when the abuse is disclosed, also appear to play a role.24,25
The following is a description of some types of difficulties that survivors may experience. Studies indicate that guilt, self-blame, low self-esteem, perceptions of helplessness and chronic danger, and hypervigilance to danger are common.5 Feelings of powerlessness may be manifested as passivity or, conversely, as controlling behavior.5 Long-term sequelae include depression, anxiety, anger, fear, dissociation, and numbing of feelings.5,26 Actions frequently used by survivors to cope with or avoid distress or pain include substance abuse and addiction, self-mutilation, suicide attempts, and eating disorders.14 Interpersonal difficulties include avoidance of intimacy and of close relationships and disturbed sexuality.5 Survivors also frequently experience physical pain and other symptoms. Some of these symptoms may be the somatic equivalent of anxiety.27
A large proportion of survivors have symptoms of posttraumatic stress disorder, similar in many ways to the effects of trauma in individuals who have experiencedcombat or in response to natural disasters or senseless human violence.28 These symptoms include re-experiencing of the trauma, persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent autonomic signs of anxiety.29 In addition, many survivors experience dissociative symptoms (for example, intrusive flashbacks of disturbing events) that are also frequently associated with trauma. Dissociation involves a "complex physiological process with psychodynamic triggers, that produces an alteration in the person's consciousness."30(p66) Thoughts, feelings, and experiences are not integrated in the usual way, and dissociation usually involves a disturbance or change in the individual's sense of identity, consciousness, memory, and experience of the environment. It is a skill that allows the individual to alter attention in various ways for adaptive purposes, but under some circumstances, it interferes with healthy functioning.31
Many of the long-term effects of childhood sexual abuse can be understood as coping mechanisms that were necessary for survival in childhood but are now responses that have outgrown their usefulness and, in adulthood, have negative effects.22 Blume points out that "by attaching the concept of ‘disorder’ we damn the-...survivor to weakness instead of attributing to her the strength of spirit that she has earned"22(p75) by having used what strategies she could, at the time, to cope with the abuse. On the basis of this perspective, we choose to use the word "survivors" instead of the word "victims" to describe those individuals who have been sexually abused.
In discussing their experiences, participants described their reactions to physical therapy in relation to their histories of abuse and their experiences of and ideas about practices that are sensitive to their needs. We have tried to quote their words as often as possible to illustrate the issues that they raised.
Safety: The Crucial Element
Aspects of a survivor's current life that evoke memories of her experiences of violation of body, boundaries, and trust reinforce her need to seek safety in the present. Most survivors repeatedly indicated that feeling safe was the most crucial element for them during physical therapy.
I now am beginning to understand that my physical wellness is really very connected to my emotional state, and if I'm not comfortable, if I'm feeling unsafe, then I'm not going to progress as quickly as a physiotherapist|| would want me to.
Survivors emphasized that safety needs to be an ongoing goal in the therapeutic relationship. In our opinion, a sense of safety is not something that necessarily can be secured during the first appointment with the physical therapist, nor is it something that either the clinician or the client can take for granted at any time during treatment. We will discuss key elements of survivors' reactions to physical therapy that they identified as being related to past abuse. We refer to these elements as "long-term sequelae of abuse that detract from feeling safe in physical therapy." We link these elements with participant-identified suggestions that could contribute to the sense of safety for clients who are survivors and thus to practices that participants felt would be sensitive to their needs. The Table summarizes the points discussed below.
Establish and Maintain a Positive Rapport With the Client
Participants emphasized the need for a positive rapport between physical therapists and themselves in order to create a sense of safety. Many survivors said that even before their first physical therapy appointment, they experienced fear and anxiety that prohibited them from feeling safe (or relaxed) and underscored the need for the clinician to make efforts to establish a positive rapport from the first moment of interaction with the client.
[Sitting in the clinic waiting room, I felt] nervous. Apprehensive, not exactly knowing what was going to happen.... Just as far as clothing was concerned or...touch, just not knowing...
Some women described a fear of being hurt or abused during physical therapy.
There's just the curtain that goes around...you see people's feet walking [by], you know, there were white shoes going this way and white shoes going that way.... It's not very secure. It's not very safe...I just remember feeling very uncomfortable being in there.... It's very hard when you're trying to pump yourself up...they're gonna be doing work on you here when you hear someone else and they're screaming in pain as the physiotherapy's going on, and it's like, "Oh! My God!"..."What've I gotten myself into?"
The importance of communication was something that the women spoke of frequently.
And to me, the main thing would be being able to sit down and talk, to know that person and feel some kind of trust, because they're a stranger...and you don't know them from anyone. Whereas, if you can sit down, talk with them, find out a little bit...[it's better]...
Good communication meant listening and letting the client know that she had been heard.
Well, I would say [the physical therapists] weren't very polite. It was very much..., "We know what we're doing and...this is what you [must] do and this will make you better,"...and I think that's why I finally blew up because...I wasn't being heard at all.
Good communication also meant paying particular attention to and responding to the client's body language. The women pointed out that they had difficulty voicing their discomfort with therapy, but usually knew that their body language spoke volumes about their discomfort.
We send out signals...to people that we have been abused.... I was sending signals out, and I don't think the people were listening really and picking up on them. I wonder if maybe the physiotherapist could have wondered [about this]...because I couldn't do certain exercises, [and] it wasn't a case of pain, [and] it wasn't a case of I wasn't [progressing], it was just a case of I had this problem. And there was a signal there. Putting hands on...you can see a person cringe and move, and I often said, "What are you doing?"
Positive rapport also meant "connecting" with the client and building a trusting relationship with her. When "connection" was lacking, the physical therapist was perceived as detached and impersonal, and survivors did not feel safe.
I experienced it as...this is just a job like any other job. She could be answering phones. And I was just another name on a [referral].... She wasn't interested. She had no warmth.... I didn't experience being safe with her because I didn't think that this was somebody I could talk to at all, about anything! She just was not interested...
Connecting often served in part to overcome the impersonal effects of therapy that participants described as losing one's identity as a whole human being and feeling like a "body part." In some ways, this experience of being treated like an object (objectification) reminded them of being abused.
Well, when I was abused, they weren't abusing me as a person, it was because of a body part...and [in physical therapy] to see me as a pulled muscle and every interaction [the clinician] makes with me is based because [I] have a pulled muscle...they're not interacting with me as a person, it's that whole detachment: "I'm doing this because you have this part..."
The issues of treatment pace and amount of individual time for the clients were difficult for many of the survivors and affected the development of good rapport and a positive working relationship.
You...got a sense, always, from everybody in there, that nobody had enough time to do anything. That they were really, really rushed and I do appreciate that they probably were. But I think that there is a way that you can be rushed and not give that aura, or use it for an excuse not to [give] explanations (about treatment).... I don't think I ever had a session with [the physical therapist] that she wasn't interrupted, and called out of the room. [At] the end of the session...she'd look at her watch and say, "Well, I have to go." And then no matter whether you were finished the conversation or not, it would just stop there.
Survivors also stressed the importance of validation of the client as a component of positive rapport. Validation refers to "normal support and reinforcement of a [person's] feelings, perceptions, ideas, selfhood and right to be who she is."22(p4) In childhood sexual abuse, when a child's feelings and needs are ignored, her sense of being entitled to respect for her needs is nullified; this situation often decreases her capacity to believe that her feelings and experiences are valid. Many participants said that hearing the physical therapist's validation of their right to seek treatment, the difficulties of coming to physical therapy, or the difficulties associated with accepting what was often painful treatment thus contributed to their feelings of safety during treatment.
Somebody [in the physical therapy clinic had] arthritis in their hip or those type of things. They had a right to be there but I felt I didn't.... I don't know if that was just me, but I think it's...not being validated that I have a right to be there, by anybody.
Establish a Partnership With the Client
As children, survivors often were not allowed control over their own bodies. Consequently, in adulthood, control is an issue of paramount importance in the establishment and maintenance of feelings of safety for many survivors. Although participants acknowledged the physical therapist as the expert on therapy, many suggested that the therapist could facilitate the survivor's sense of control over her own body, thereby increasing feelings of safety during treatment by sharing control in the therapeutic relationship. In this way, the therapist and the client can form a partnership in which the client truly feels the comfort of being a respected, active participant rather that a bystander during treatment.
Making an open statement in the first visit, just saying, "If you're not comfortable with me, there are other options.... Or if you're uncomfortable with anything that I do, please raise that issue." Just having more control. I think [it is important that the physical therapist offer] a real clear statement and reminders throughout-you can say, "Stop," or "Wait," or "Change." You know? And it has to be instant. If somebody says, "Stop," you stop...
Although informed consent is a component of control, most participants said that it was important that the clinician seek consent before every step of treatment.
And [the physical therapist] would sort of tell me, "This is what I'm going to do," and she would sort of show on herself a little bit, and then she'd ask am I comfortable with this? And I'd say yes. And so she'd normally put an ice pack or a heat pack on me and then come back in 15 minutes. When she came back, right before she was gonna [proceed with further treatment], she'd ask me again, "Are you comfortable with this? Is everything all right? And do you understand what I'm doing?" And that was so much easier, because one minute, yeah, you can feel comfortable, and the next minute, you could feel uncomfortable...so she gave me an opportunity that, if I were to change my mind and feel uncomfortable, all of a sudden, for whatever reason, she would know, and I'd be able to say something. So I felt like I was in control, and I did have the say of what was going on.
Many survivors emphasized that they experienced periodic shifts in comfort, boundaries, and tolerance for certain parts of treatment. These shifts sometimes meant that they needed to exert control, because they were too uncomfortable with certain parts of treatment. One woman spoke about the need for her wishes to be respected.
If I say today, "No. I don't think I can handle you doing that," not to be treated like some sort of baby...or..."What's your problem?" kind of thing...but to accept that when I say, "No. You can't touch my neck today. You know, maybe tomorrow but you can't touch it today..."
In order to share control, both the client and the clinician must feel that they are able to exert that control. Many survivors learned as children that they were not allowed to speak up, that they were not allowed to say "no," and that their feelings were not important. The physical therapist's giving the survivor permission to say "no" and inviting her feedback are important ways of sharing control and showing respect, especially for those who have begun only as adults to learn that their feelings are important and that they can say "no," as this survivor described.
I think...[offering control, giving permission to say "no"] would have given me an opportunity just to learn how to talk.... That assertiveness of "no" takes a long time to get ...when I initially started [to try saying "no," my support group] would give me permission to say "no." And it was somebody else giving me permission that allowed me to say "no" until I could learn to give myself permission to say "no," or find out what helped me best.
Participants described how, as adults, their hesitation to express their feelings may have been manifested as passivity in circumstances that they felt were out of their control.
[The therapist did something and] I really freaked but...I didn't show her I was freaking, because our history is that, you don't let on if things are a problem for you. You just deal with it however you can...by dissociating or what have you.
Denying the survivor a share in the control of the treatment mimics the dynamics of her history of being abused. Many participants said that for them, the alternative to the sharing of control with the clinician was that they could not continue treatment.
I'm learning that if I don't have a sense of control,...I will walk away from [the situation].
Other participants described the extreme difficulties that they had with physical therapy when they did not feel in control.
[Giving consent for touch during therapy is] a choice that you have, and that's very important, I think, to me anyway, being a survivor. I have to be in charge, I guess, and if I'm not in charge...it's an awful feeling...I want that person out of here...if you were allowed to, you'd scream, "Get out... leave me alone." But, of course you don't do that.
The women also spoke frequently about how the desire to feel in control also applied to the pace of the appointment; for many, the pace of each treatment session was just too fast for them to feel comfortable and safe.
Offer the Client a Choice of a Male or Female Physical Therapist
Although children are sexually abused by both men and women, the large majority of perpetrators are male.32 Many women spoke about feeling vulnerable and unsafe with male physical therapists or around male clients.
Being in an enclosed room with a male...it was difficult. I tried not to make it difficult because he was a very nice man...not related to my past experiences at all, but...you're just in such a heightened panic state that anything could set you off.
Although most survivors expressed a preference for female physical therapists, this preference was not unconditional.
For many survivors, being offered a choice of gender of the physical therapist was an important form of control. Most participants were not comfortable raising this issue with the clinician and so suggested that they be offered a choice of male or female physical therapist.
I was assigned a male physiotherapist, which I think was part of my discomfort. But I didn't know at that time to ask for a female physiotherapist, because I really didn't know. I just didn't know how to deal with that kind of thing.
Share Information: A Critical 2-Way Exchange
The sharing of information about the process of physical therapy and about treatment itself was crucial in the development and maintenance of feelings of safety for most participants. Many women reminded us that physical therapists should not assume that the client knows what physical therapy involves, what the clinician is doing during treatment, or what the clinician expects of the client. They urged that physical therapists put careful, ongoing effort into these explanations.
I found quite often when you go to a doctor or physiotherapist, they automatically assume that you have some kind of knowledge of their job outline.... And why should I know? I didn't go to school for that, so it's really frustrating. And they expect you to know something about it...
Participants repeatedly stressed that they needed to be offered information about treatment on an ongoing basis.
[I think they should] spend the 5 minutes at the beginning saying, "This is what physiotherapists need to do to figure out what will best work for you," so that we're prepared, you know. The element of surprise is just really, really difficult to deal with...[and if] there's a preparation and there's not that fear of the unknown, and not the likelihood then that I will be triggered by something that is done, you know, into remembering something that is abusive for me.
Many women spoke of their strong reactions when they were not given information.
What I found with physiotherapists, doctors, massage therapists—the doctors that just go about their business and do what they have to do for their job, and that's when I get really uncomfortable and I tense up. And I want to just push them away, and I want to run, leave.
Many women said that information sharing needs to be reciprocal: the physical therapist offering information about the therapeutic process and about her or his findings and the client offering information about her reactions to treatment. They suggested that the physical therapist should invite feedback rather than expecting the client to offer feedback without being asked. They reminded us that a daily "check-in," ongoing invitations for the client to let the clinician know how she is feeling, and taking the time to obtain ongoing consent were crucial to the survivor's feelings of safety.
Parts of my body at different times might be untouchable. It's gonna change, depending on what I'm dealing with. So, you're not going to be able to make a list and count on that every time kinda thing: it's gonna be a check-in every session.
Convey Understanding and Work With the Survivor Concerning Her Attitudes About the Body and Pain
Many women spoke about being disconnected from their bodies and feeling hate or shame about their bodies. These reactions are very understandable when one remembers that the target of the sexual abuse was their body, and to their child's mind, their body seemed to be the cause of the abuse.
And [the amount of attention that I give to my body] ebbs and flows, too, depending on where I'm at and how well I'm choosing to take care of my body. Which is a very difficult thing for me physically to do, because when you don't live there, it's just sort of a vehicle to get around.... The fact that most survivors I know hate their body, disown their body, just have dissociated, become disconnected from it...and that's how they've dealt with pain [and other aspects of abuse]...
In addition to the ambivalence about their bodies that arose from their histories of being abused, the experience of pain was directly linked to the survivors' childhood abuse experiences. Thus, for many participants, their pain contributed to their feelings of being unsafe.
I think sometimes when survivors are in pain, and coming for physiotherapy, it hooks us back into a time of...our childhood where we were in pain and in fact no one responded. And if you did indicate you were in pain...the pain was trivialized or you were threatened [to] not tell anyone...
The childhood message may often dominate the survivor's reactions to pain. One participant contrasted the way that she had learned to deal with pain when she was a child with the way that she was encouraged to approach pain as an adult.
My ankles hurt, [and the physical therapist says] "...what we can do to make them better." It's not the experience of a survivor when they're little. The experience [as a child] is to discount the pain, to threaten them, to say, "Don't tell anyone about this," to hide the pain, to begin to disassociate from the pain.
Many women spoke about the process of connecting with and learning more about their bodies during their journeys of healing from childhood sexual abuse. These women also spoke positively about learning about their bodies from the physical therapist.
[Interviewer's Question: Is there anything else that you want to say about physiotherapy and how physiotherapists could be more sensitive?] Just the whole aspect of how healthy it has been for me to start to get in touch with my body, and...just how I think that a physiotherapist can really affect that, [by giving] that supportive invitation to like come back into their own body.... I think it would make a big difference in doing the work...
Survivors recommended that physical therapists both encourage and model self-care.
[It would be very helpful if the physical therapist would give] reminders for...a follow-up support of, maybe a counseling appointment...women in general need reminders about self-care. You know, "Can you go home today and do something nice for yourself? Take it easy? Relax?".... Or [validate] the energy and the courage that it takes to go through physio...validating how hard that is.
Work With the Client on Difficult Physical Factors
Survivors spoke of a range of physical factors that detracted from their sense of safety. Some participants described how their sensitivity to the environment of the physical therapy clinic or department and their physical position within the clinic affected them.
Survivors...like to see a door, [they] don't like to sit with their back to the door.... [At] the clinics that I've been in, they're huge rooms, and if separated, separated by a curtain.... I think that the clinics that I've been associated with aren't set up to make survivors comfortable...
The lack of privacy was often linked with feelings of vulnerability and thus of feeling very unsafe.
I felt...uncomfortable [in a curtained cubicle] ‘cause I thought, anybody could just open up those curtains at any time.... I found when people would walk by, or they'd sort of bump it on the other side ‘cause, you know, the cubicle, the curtains would sort of move, and I didn't feel as safe or as if this was my space. I felt like, at any time it could be invaded, or that—I was really vulnerable.... You hear everything around; people sort of mistake and they come into the wrong place, and it's—I find it's uncomfortable, because you're worried—what if someone does come in? Or, what happens if I can't hear them open the door if I'm not ready? All they do is, they sort of move the curtain. Um, it doesn't feel very personal, it doesn't feel private, it doesn't feel safe.
Although most participants expressed anxiety about the lack of privacy in curtain cubicles, a few women described their ambivalence about seeing physical therapists in separate rooms.
I just was thinking about the [treatment] room being very open, and I'm not sure that it would have been better to have separate rooms...like I mean it might have been worse to be alone with this person than to be in the whole room, you know, that sort of a 50–50 thing because being with all those people was uncomfortable, but being alone I think would have.... I mean the times that he did pull the curtain around, that was high anxiety, so I think maybe the open room is a good thing.
One woman spoke about how her physical therapist combined the 2 types of settings to her client's benefit.
For [personal parts of treatment]...I was in a real room with walls and stuff. And that...made more sense to me, and it made me feel more comfortable because when you are doing something personal, yes, it is more important, and it's something different, it's not everyday normal stuff...that's what I felt like when she brought me into the real room with the walls. It felt like she was acknowledging, "Hey, this is something different; this is private. And, it shouldn't be shared with everybody.... You should have privacy...." That was really nice.
Survivors also described discomfort and vulnerability related to types of clothing and disrobing for physical therapy.
They're gowns, but they're paper, you know. And the first time I went there and I had to wear this thing, I felt so exposed and so naked and, and hated it.
Survivors spoke about feeling the power imbalance that was reinforced with disrobing.
But what happens is, they tell you to get undressed, and then this person comes in and talks to you...and you're sitting there talking to someone who's fully [clothed].... It's a totally unequal...situation.... If you want to get around that, I suppose the best bet is to talk first and explain what's gonna happen and everything, and then get the person to get undressed.
The issue of touch merits special consideration both because of the use of touch in physical therapy and the negative feelings that touch can elicit for many survivors. The touch that is intrinsic to childhood sexual abuse is associated with painful feelings and memories. As a consequence, many survivors have described fear and apprehension related to touch by professionals as well as reluctance to voice these difficulties. Some women were able to tolerate touch as they developed trust in their physical therapists. For other women, touch was difficult regardless of the circumstances.
[Having to go to a physical therapist] kinda bothered me, because I don't like to go to a place where people are going to be touching me.... Whether it's my head or my toe, I don't like that.... And I don't want the people to feel uncomfortable that I'm saying..., "I really don't feel comfortable that you're touching my head or my foot." Because I don't want them looking at me like, "What are you, bonkers? I'm just touching your head or your foot! Like, no big deal!".... And a lot of times...the thought of going to see somebody that's going to be touching me, then I start thinking about my past. And then I really start stressing out. ...I do know the feeling of..., "Don't touch me," unless the person has said to you, to start with, "Is it okay, I'm gonna put my hand here, I'm gonna lift your leg, I'm gonna put my hand on your, under your thigh, and I'm gonna put my hand," then as I said, you have the choice, it's up to you...and you'll say, "Yes," so then therefore you can, it's my decision, and to me, I think that's very important, I made the decision.
Some survivors described certain aspects of treatment (for example, a certain position during treatment or certain exercises) that they were unable to tolerate or that increased their discomfort with therapy. These women's words underscore the need for the physical therapist to seek alternative positioning and exercises.
There may be some positions for me that are particularly distressing, like I say, on my stomach, ‘cause I can't see and I feel pinned...
There's some of the exercises...that they wanted me to do [after a total hip replacement].... And one of them that I still today cannot do, and I'm trying...it's like when you lie on your side, I don't know what you call it, it's a scissor...it's just like I'm opening my legs to something that I just won't do. There were some [exercises] I could do, but this is one... there was no way, and I mean even when...[the physical therapist] had the sling or something like that around my ankle and it had a handle and I could pull it and my leg would go up, I couldn't even do that. I'd get it so far, but I wouldn't go any further because I had to keep [my legs] so tight...[and the physical therapist] got frustrated, she really did...she thought I wasn't trying, and that wasn't true at all because I was doing the other ones very well.... Even at the end of the year...I could do some of them, but I couldn't do, especially anything that had to do with, you know, spreading my legs, I could not.
Understand and Respond Sensitively to "Triggers" and Dissociation
Issues that have been discussed above, such as difficulty trusting, the need for sharing information and control, ambivalence about the body, pain, and touch impinge on the physical therapy experience and can be understood as being related to the psychological phenomenon of transference. This term refers to the transferring of feelings and perceptions about past situations to experiences in the present. All human beings experience transference. For example, a person whom we have just met may remind us of our best friend from childhood, and we may feel immediately drawn to that person. Although transference may be positive or neutral, it can also be negative and can interfere with our normal functioning, as illustrated in the words of one woman.
[My fears in physical therapy] didn't really hinge on the [physical] therapist. It hinged on [the fact that] I had problems and I hadn't dealt with my problems, so I didn't know why I was reacting the way I was. It wasn't until I got a social worker and...a psychiatrist...that I realized that some of my problems didn't really hinge on the therapist, it hinged on that all from my background...they triggered all my childhood fears.
Survivors tended to use the word "trigger" to refer to sudden intense emotional reactions or flashbacks that were precipitated by an experience that in some way reminded them of the abuse. They described memories and feelings, such as fear, anxiety, terror, grief, or anger, that suddenly and without warning surfaced after being "triggered" by some aspect of physical therapy.
And the goop that they put on me for the ultrasound gave me flashbacks, nightmares, insomnia. I just couldn't deal with it.
Participants had a wide range of understanding about circumstances that had been or might be triggers for them. Some women brought to treatment an awareness of many of the actions or conditions that were potential triggers for them.
I guess a physiotherapist might be a person who's very comfortable with bodies and very comfortable with how the body works, and how to get people's bodies working better ...and for people who were abused, bodies are not at all comfortable things...if [physical therapists] could really understand how traumatic it is to even be touched on your arms, that it just brings back old feelings and helpless feelings...and if they could know, too, that, you know, things are flashing before your mind and that you're not just in the physiotherapy room, you're also stuck back in past time, so it's an extremely stressful thing, it's not just mildly stressful.
Other women described reactions that they did not understand at the time of physical therapy but had since come to understand.
[During] my first experience [in physical therapy], they didn't have any Kleenex, and the minute she was touching me I just started sobbing, and like just not having any idea of like why.... I just remember her not having any Kleenex, the physiotherapist, and she couldn't handle that I started crying like that, and she walked out. She just left me laying on the table and said she.... I don't even know if she told me she'd come back.... She just walked out...
These quotes illustrate how intense the experience evoked by physical therapy can be for many survivors. Understandably, some women described experiences that made them feel so unsafe that either they could not adhere to the treatment regimen or they could not return to physical therapy.
The second visit, again, I had to lay on the table and...he didn't warn me and all of a sudden...I heard the whirring, and he raised the table and [I was] coming toward the ceiling, I just felt attacked.... But I kept it inside and didn't tell him what was happening. But I didn't go back. That was just too much.
Survivors reminded us that it is important for the physical therapist to be able to respond to the client if the clinician suspects or knows that the client has experienced a trigger.
Now, [physical therapists] don't have to handle the [whole] crisis, but they do need to know how to recognize [it]. And how to make a referral in a nice way, as, you know, "Do you see your counselor tomorrow?" or "Is there someone you can talk to?" They would definitely have their scope and they wouldn't need to go beyond that...just basic humanity and reassurance. You know, "You're okay, it's safe here" ...and "Yes, [physical therapy] can trigger memories, and it can be really disturbing and distressful, and what you're feeling is normal."
Some participants who coped by dissociating spoke about the need to have information repeated and written down for them.
I do have a lot of problems with dissociation...and so...what I hear one day won't be what I hear the next day at all...
And [it is important for the physical therapist] not to...say, "Well, I explained it to her once, way back when. She should understand." Or to assume that I still remember and I still know.... I find an awful lot of help if they write things out.... Because I will invariably get home from that kind of thing and not have a clue.
One woman who had chosen to disclose to her physical therapist that she was a survivor spoke about how knowledge of her triggers could be transformed into questions that were highly pertinent to therapy.
I think [it would be important for the physical therapist] to ask, "Do you think there's anything that will trigger, or do you think there's anything that I do, or anything that you can think of that will create problems?" And, "Is there anything that I can do so that we don't create problems, [un]necessarily?"
Respond Carefully to Disclosures of Abuse
Disclosure is a multifaceted issue that cannot be presented in its entirety within this article. We have chosen to highlight only some of the most important points that participants discussed and direct the reader to Teram et al33 for an in-depth discussion of the issue.
Participants expressed considerable diversity of opinion regarding disclosure of information related to their abuse. Their opinions could be seen as representing a continuum, from clearly identifying themselves as a survivor of abuse at one end, to revealing discomfort or difficulty with certain aspects of physical therapy (without verbally linking this difficulty to past abuse) at the midpoint, to the complete avoidance of any disclosure at the other end. Opinions regarding physical therapists' inquiries about abuse mirrored this continuum. At one end, a few participants advocated that the physical therapist inquire routinely about experiences of abuse during the initial encounter; at the other extreme, a few women felt that it was not appropriate for the physical therapist to inquire about abuse at all. Between these extremes were survivors who suggested that inquiries would best be limited to the identification of discomfort or difficulty with certain aspects of therapy. Several women suggested an open-ended approach that would allow the survivor to choose her level of disclosure. According to Teram et al, "The challenge is to satisfy these diverse preferences, while taking into consideration survivors' differential personal development, and professionals' varying ability and willingness to deal with disclosure."33
Survivors stressed that the clinician's response to the disclosure affected their feelings of safety. They suggested that the least appropriate responses are to ignore or react negatively to the disclosure.
[In physical therapy] I wasn't feeling safe enough [to disclose] or I wasn't sure [about whether I should disclose], because I've had experiences before where I have mentioned it, and someone has just freaked out or else they've looked at me like, as if I'm from a different planet, like, what am I doing even sharing this with them? Or even mentioning it. So I'm really hesitant on mentioning it to people, especially in the [health professions].... I don't want to start talking about it or mention it, and get that rejection. ‘Cause that's the worst. ‘Cause then I clam up and I—my headaches will probably get worse and everything will just get worse.
The following words of one participant illustrate what many suggested were the basic elements of appropriate responses: acceptance and acknowledgment of the abuse and of its consequences for the survivor.
[If a client discloses a history of abuse]...it's really important to know that you believe them, because this might be the first person they've told. And also, it's really [important]...to accept them as a person, like...you can say whatever your real feelings are: "I'm really, I'm really sad to hear that," whatever,...and also...don't push the person...[and] be really aware not to use the "shoulds," like you "should" call the crisis line, you "should" see [a counselor]...
It is clear from the interviews that whether the survivor has revealed her history of abuse or has limited her disclosure to difficulties with certain aspects of therapy or the clinician has noticed nonverbal signs of discomfort, a discussion between the physical therapist and the client about the implications for the therapeutic relationship and therapy is important. Ideally, this discussion will focus on the client's needs and expectations and what the professional can offer.
Whether in reference to verbal or nonverbal signs of discomfort with certain aspects of therapy, participants repeatedly stressed that identifying and addressing difficulties by problem solving and implementing alternative strategies were crucial to their sense of safety and thus their ability to remain in and benefit from physical therapy.
If [a certain aspect of treatment is] not comfortable for me, then we can work together to make it OK. Like, "What do I need to make this work?" Because let's face it, if I'm really tense and that's something that you're gonna do, then whatever you're gonna do isn't likely to work.
Practice Holistic Health Care
"Holistic health care" can mean many things. For some participants, holistic care involves acting on the kinds of considerations discussed throughout this paper: establishing a positive rapport, sharing control and information, and treating the client as a partner in treatment.
I think the most important thing for me is to be treated as an individual, which means talking to me without becoming too personal, giving me the information that I require, and the third thing would be to treat my body with respect—give me privacy, don't become familiar in the way you touch me—those kinds of things.
Many survivors stressed the importance of the health professional's recognition of something that they firmly felt: that one's life experiences and emotional state as well as one's body contribute to health and well-being.
[A better approach would be to use] a more holistic attitude, where [physical therapists] could shift their mind set.... I believe it's possible for somebody's mind and body to communicate...from my experience, the physical therapists I've seen don't have an understanding of that. And if they did, then you could have some really good communication with the people who are coming in to see you...
Some women stressed that holistic practice involves facilitating links between the client and many health care professionals.
I think [physical therapists] have to know who the good [counselors] are that are gonna believe [survivors]. I think that...medical people have to be very, very responsible in who they refer people to...[someone] who understands the role that violence plays in the lives of women and children. I think that's critical.... I think that we're talking about really long-term partnerships with a number of medical people, you know, maybe a physiotherapist, a psychotherapist, a family doctor, you know. We need those nuclei of support, and they all need to be in touch with each other...
Survivors also emphasized that to practice in a holistic manner, the clinician needs to understand the dynamics and long-term sequelae of childhood sexual abuse. Some women said that they deliberately avoided a health care professional who was not knowledgeable and sensitive to issues of childhood sexual abuse.
The experience was not beneficial at all.... The [clinician] I went to, I felt, was not sensitive at all to the issues of survivors and had no understanding whatsoever about issues that may be a problem to a survivor. And so, I decided that I was just better off avoiding a community that probably was not sensitive to what I was dealing with anyway.
One woman summed up her feeling about working with a knowledgeable, sensitive clinician in this way.
So, what we have is a relationship of, I think, mutual give and take, that she gives me a lot of responsibility, I give her a lot of information, we negotiate how best to work with me to help me to fulfill my needs and to let me have power over my own life.
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TopAbstractIntroductionThe StudyDynamics and Long-Term Sequelae...ConclusionsReferences |
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The core experiences of psychological trauma, including childhood sexual abuse, are disempowerment and disconnection from others.23 Recovery, therefore, is based on the empowerment of the survivor and the development of new connections. Recovery can take place only within the context of relationships; it cannot occur in isolation.23 Although physical therapists should not be expected to perform psychotherapy, they can encourage a new and healthful connection between the survivor and her own body and can contribute to a positive connection between survivors and themselves by using the knowledge and ideas suggested by this research.
Readers will recognize that many of the suggestions made by the participants of this study quite simply represent good physical therapy practice with all clients. We heartily agree. Practice that is sensitive to survivors of abuse is the kind of practice that all clients appreciate. We hope that by providing information about the prevalence and long-term effects of childhood sexual abuse and by sharing the powerful words of the participants of this study, we have enabled more physical therapists to recognize that they have something very important to offer these clients: practice that is sensitive to the needs of survivors is definitely within their scope and ability.
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This research was approved by the University Advisory Committee on Ethics in Human Experimentation (Behavioral Sciences), University of Saskatchewan, and the Research Ethics Committee, Wilfrid Laurier University.
This work was supported through a University of Saskatchewan College Medicine Teaching and Research Fund Grant, a University of Saskatchewan President's SSHRC Grant, and a Wilfrid Laurier University Short-Term Grant.
* Ritual or ritualistic abuse is "abuse that occurs in a context linked to some symbols or group activities that have a religious, magical or supernatural connotation, and where the invocation of these symbols and activities, repeated over time, is used to frighten and intimidate children."15(p59) 
Métis refers to "people who have a mixed biological and cultural heritage, usually either French-Indian or British-Scottish-Indian."18(p10) Today, the term refers to those people who identify themselves as Métis.19
Folio Corp, 5072 N 300 W, Provo, UT 84604.
These dynamics also apply to male children.
|| In Canada, the term "physiotherapist" refers to a physical therapist, and the terms "physio" and "physiotherapy" are frequently used to refer to physical therapy.
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