Survivors who contact us raise many important questions. Here we offer some answers and perspectives.
What is abuse and what is trauma?
Many people contact us because they are not sure whether their childhood experiences count as abuse. Some compare their experience to other people’s and feel what happened to them was not as bad. Others are very clear that what they experienced should never have happened.
There are many formal definitions of abuse and trauma but the only one that matters is yours. Only you can know whether what you experienced felt abusive and has had a harmful impact on your life. If you are still struggling with what happened to you in childhood, if the memories of what happened still bring you pain or distress, it is very likely that you experienced some type of abuse or neglect.
Abuse and neglect, whether short term or over many years, are traumatic experiences for a child. They threaten our sense of physical or emotional safety or even our life and overwhelm our nervous system. The effects of the trauma are deepened if it’s not possible to escape the threat, which is naturally the case for (most) children.
All types of abuse—physical, emotional or sexual—and neglect can harm, regardless of whether it happened many times over many years or whether it happened just once. Once is too much. What matters is the impact it has had on your life.
Many different factors play a part in how well our bodies and minds cope under the stress of abuse and neglect – your age at the time of the abuse; the relationship to your abuser; the type of response you received when you first spoke about it; the level and quality of support you received (if any) and many more.
To further reflect on this issue, please review the NAPAC booklet “Was it really abuse?”.
Is my mental health diagnosis linked to the abuse?
Many survivors who contact us report a range of different mental health diagnoses that they received at different times in their lives and which many experience as labelling or confusing. These diagnoses typically end in the word ‘disorder’. One of the world’s main mental health diagnostics manual, the DSM-5, lists an astonishing 297 ‘disorders’.
It is not only many of our callers but also a growing number of mental health experts who actively challenge why we have come to view emotional distress as a ‘disorder.’
The traumatic experiences that caused the distress were abnormal – not our response to them. Emotional distress is an appropriate response to threatening, abusive, traumatic or otherwise harmful experiences. It tells us something is wrong.
We now know that chronic stress from abuse and neglect in childhood harms our developing brain and body, and therefore how we think, feel and behave in adulthood. The good news is that there is also growing evidence that these effects can be healed over time.
Among the most common diagnoses reported by our callers are depression, anxiety, borderline personality disorder, bipolar disorder, schizophrenia, dissociative identity disorder, eating disorders and ADHD. Recently, more callers are reporting a diagnosis of post-traumatic stress disorder (PTSD) which, while more accurate for one-off trauma, still does not fully capture the complexity of long-term abuse in childhood.
Complex trauma—the diagnosis that we feel most accurately describes the key symptoms of long-term child abuse—will be included in the World Health Organisation’s diagnostics manual (ICD-11) for the first time (albeit as Complex Post-Traumatic Stress Disorder) and is already recognised by the NHS. This diagnosis was first suggested in 1992 by leading incest and traumatic stress researcher Judith L. Herman to capture the long-term effects of childhood abuse and other types of violence between people.
The key symptoms of complex trauma are:
- consistent sense of threat (hypervigilance)
- re-experiencing the abuse (flashbacks)
- avoidance of anything that is a reminder of the abuse
- difficulties managing emotions
- difficulties relating to other people
- a negative (or weak) sense of self
Many who have experienced abuse—or have been working with people who have—recognise that the medical community’s focus on symptoms rather than causes (asking “what’s wrong with you?” rather than “what happened to you?”) makes survivors feel blameworthy, powerless, deficient and separate – just like the original abuse made them feel.
It is worth noting that some survivors who call us initially embrace a diagnosis of a mental health disorder in the hope that it will finally open a door to receiving support. Others may simply experience relief from being able to give a name to the symptoms they are struggling with.
Whatever perspective you take, remember that you are the expert of your life experience. Only you have lived in your body all this time. When reaching out to someone to address any symptoms that you feel are linked to your abuse, practitioners should always work in close partnership with you instead of merely prescribing treatments that they feel are right for you.
Understanding the underlying causes for your distress is crucial to your recovery. If you aren’t already a dedicated researcher on the topic of abuse and trauma (many survivors who call us are), then now may be the time to start. Our Recommended Reading page lists what we consider important books on the topic of abuse, trauma and approaches to recovery.
How can therapy help?
Abuse in childhood has a profound impact on a person’s ability to trust other people. It therefore makes sense that one of the key tasks in our recovery from abuse is to learn how to regain that trust and connection to other people.
A therapist, counsellor or any other person who you feel safe with can play a key part in this process. Their main task is to offer safety, support and unconditional positive regard. Advice and direction should only be offered if you ask for it. Therapists should never try and convince you that they know what’s best for you or disempower you in any way. Their role is to show you what a healthy relationship with another person feels and looks like.
In the first instance, a therapist or other supportive person may help you with addressing some key symptoms of abuse that you feel you are struggling with the most – for example, depression, anxiety, self-harm, addictions, or self-sabotage. As trust and connection builds, they can then support you with slowly and gently facing up to those feelings that you may have suppressed for many years.
At first, you may feel worse as you go through the process of engaging with very painful feelings. This is normal. You are facing up to something that you had to push aside for a long time in order to survive. But with the right support this process will make you feel stronger in the long run and allow you to fully take charge of your emotions, your thoughts and your life.
There are many different types of therapy but almost none of that matters. What matters is whether you feel safe with your therapist, counsellor or supportive person and whether working with that person is making a positive difference in how you feel about yourself and others and the world.
Not all therapy is talk therapy. There is body-centred therapy, art therapy, dance therapy, equine therapy, psychodrama, EMDR, trauma release exercises, and many other approaches that can support you in dealing with the impact of the abuse. Find out what resonates the most for you and explore. Many of these approaches are available through the NHS.
If you choose to find therapy outside of the NHS, many private therapists or private or third-sector organisations offer “pay-what-you-can” or sliding scale options for anyone who is struggling financially. Don’t feel shy about asking for such options. They are common.
While qualifications and membership of a professional association may offer some protection from malpractice by therapists, they do not guarantee that he or she has the human qualities and skills needed to work with abuse survivors. We have heard from many callers who said they felt most supported by someone who simply had the capacity and willingness to do so – a neighbour, a community mental health nurse, a support worker, a student counsellor and many more who may never had any advanced training. Research has shown that most survivors feel best supported by people in the voluntary/charity sector where they felt heard, believed and respected.
If there is something that you do not feel comfortable with when working with a therapist or counsellor, and it could not be resolved by talking to them directly, you can contact their professional association or employer to get advice or make a formal complaint. BACP and UKCP, the two leading professional associations for therapists, outline the process on their respective websites.
Group work – whether it’s group therapy, psychoeducation groups or peer-led support groups – is also known to be highly empowering for abuse survivors who feel ready to join a group. Many survivors build up confidence in one-to-one counselling before connecting with a group; others feel more comfortable being part of a group before moving on to individual counselling or therapy.
NAPAC knows from experience that support groups can transform lives. We will continue to offer support groups whenever funding permits, but please also review The Survivors Trust website to find other organisations running groups in your area.
Some survivors have also found it useful to join peer-to-peer support groups such as CODA, Al-Anon or ACOA – all of which address the impacts of having grown up around people who were abusive, neglectful or otherwise unable to support a child.
How can I overcome my fear of medical examinations?
Many survivors we hear from talk about their fears when having to access health services, particularly sexual health, gynaecology and breast wellbeing for women, prostate cancer screening for men, and dentistry for both women and men.
Aside from the very real fears that many survivors feel about accessing these intimate forms of health care, NAPAC is also aware of the lack of self-worth many survivors suffer and their felt sense that they are not deserving of health care or they have no right to express their needs.
Although each survivor’s experiences are unique and different, we often hear description of similar experiences with medical examinations. For some survivors just receiving a reminder from a medical practice is enough to trigger flashbacks, panic attacks and much fear. Any examinations themselves have the potential of being highly retraumatising.
Survivors may feel that they are not understood by health practitioners and that they are not in control of their body during examinations. Female survivors also talk about their fears that a smear test will cause physical tension or freezing, making it an extremely painful experience.
Having a negative or even retraumatising medical examination can prevent survivors from attending future testing, which will increase the risk of illness and disease. Survivors are of course aware of this risk, but we repeatedly hear that some would rather deal with the consequences later than face the experience of regular check-ups or testing.
The following steps may help you overcome at least some of your fears and feel in control when preparing for a medical examination:
- Talk to your practitioner at the start of the appointment – explaining that you are highly anxious about medical examinations. You do not have to give any reason – even if pressed. Simply making them aware that this is an extremely challenging situation for you can alert practitioners to proceed with greater care.
- Ask a friend or supporter to be present during any examination – giving the same reason as above.
- Tell the practitioner how you want to be addressed and receive any instructions that are needed for a successful completion of the examination. The use of pet names (‘darling’, ‘love’, ‘sweetie’ etc.) that are still frequently used by health practitioners are triggering for many survivors. Telling a survivor to ‘relax’ during an examination can also be retraumatising as this is something that an abuser would tell a child. Although some NHS guidance has improved recently, many practitioners are unfortunately still not trained in trauma-informed practices and will have an opportunity to learn from you when you express your needs. Moreover, you will feel empowered by expressing your needs.
- Explain that you need complete privacy when undressing or changing for the examination.
- Agree a clear signal with the practitioner that will prompt them to halt the test at any time.
Always remember that you have the right to be treated respectfully and that you are equal to the practitioner working with you. Just like everybody else, you have the right to ask for what you need to be able to take care of your physical health.
Why do I feel guilt and shame?
A large majority of survivors who contact us report that they were sexually abused by someone in their family or someone they knew. This means that they probably already had an emotional connection with their abuser or that the abuser deliberately developed this connection with the intent to abuse.
The process of developing a connection with the intent of sexual abuse, commonly referred to as ‘grooming’, typically involves the abuser identifying what is lacking in the child’s life and then meeting those unmet needs. The abuser might offer the child anything from food, attention, physical care and touch, clothing, toys, day trips or anything else that the child needs or desires.
It is completely normal—and crucial for survival—that children feel drawn to people who meet their needs. However, abusers deliberately manipulate this need to get physically closer to the child, win their trust, and eventually sexualise the relationship. This process can take months or even years and often also involves the grooming of the child’s parent or caregiver. If the parent or caregiver perceives the abuser as a helpful, generous, upstanding citizen, they are far less likely to believe the child if she or he discloses the abuse at the time or in the future.
The main reason abusers go through such lengths is to prevent getting caught. The emotional manipulation leads to many children feeling that they chose to go along with the abuse, making them far less likely to disclose to someone else what is happening. In the long term, survivors are left with a crushing sense of self-blame, shame and guilt that can carry long into adulthood. The transfer of responsibility from abuser to child is complete.
The confusion a child experiences when abused by someone they loved and trusted is a form of psychological harm that for many survivors is more devastating than the sexual abuse itself. It robs them of the ability to trust anyone who offers care, attention or gifts later in life, deepening their sense of isolation and robbing them of the crucial benefits that come from the ability to form healthy and supportive relationships with others.
It takes time to untangle this “web of confusion” and free ourselves from the burden of responsibility that was never ours. Most survivors do so when they start connecting with a counsellor or therapist or another supportive and trustworthy person in their life.
Read more in “What does recovery look like?” in the section below.
Should I disclose my experience of abuse and, if yes, to whom?
There is a long list of reasons why people who suffered abuse in childhood are reluctant to talk about it and may never do so. The majority of our callers did not disclose until decades after the event. Saying out loud what happened to you is a challenging but profound experience. For most, it is a crucial step in their recovery journey.
It is equally important to consider who to disclose to and what the consequences of the disclosure might look like. First and foremost, it is important to consider potential consequences of a disclosure for you. Disclosing to a person who is unable to listen and respond appropriately can be highly retraumatising – in other words, trigger physical and/or emotional responses reminiscent of the abuse. Reflect with care on who to choose as a safe and appropriate recipient of your disclosure – whether it’s within your family, among friends or a professional.
Making a disclosure may affect your family in many ways, irrespective of whether the abuse took place within the family or not. Callers to our support line often speak about how their disclosure caused a split in their family or among their friends who, for their very own reasons, take sides with the survivor or the abuser. For example, we frequently hear about mothers taking side with a father, step-father or partner who has been abusing their daughter. However, a disclosure also may unite a family to tackle the problem together, sometimes through family therapy. We hear more often about negative effects on the family, but of course that’s also because people who have had a positive experience with their disclosure are less likely to call us for support.
If you decide to disclose to an employee of a statutory organisation (such as the NHS, police, schools or any other organisation funded or regulated by the government), their Safeguarding policy may require them to share your information with others – even without your consent. However, we believe this should only happen when it is clear that they can prevent potential harm to you, a child, or a vulnerable adult or the breach of confidentiality is otherwise in the public interest.
When reaching out for support, it is important that you know in advance what the person or organisation who you disclose to is likely to do with the information. Before disclosing, ask them exactly what they can and cannot keep confidential so that you can make an informed choice and remain in control of the situation.
You never have to disclose any details of your abuse when you seek support. You don’t have to say what happened, who was involved or give any identifiable information. You don’t owe anybody anything. You could simply state that you were abused but are not ready or willing to talk about the details. This will help keep the focus on what you need now and ensure that the provider will offer appropriate support and services.
You might get pressed to provide additional information, but you are never under any obligation to give it. Without names, times and/or locations, a professional has no cause to breach confidentiality.
The most important questions you may want to ask yourself are:
- Why do I want to disclose? What is my key motivation?
- What do I hope the disclosure will achieve?
- Will I achieve this outcome when disclosing to this particular person or organisation?
- Who else could I speak with who I know will keep the information confidential?
What does recovery look like?
The short answer is that recovery looks different for every single survivor. There is no clear-cut path and many survivors talk about going through peaks and troughs as they face up to what happened to them and the effects it had on their lives.
Nevertheless, there are common patterns and useful approaches that some survivors find helpful. In her book “Trauma & Recovery,” Judith L. Herman developed a three-stage sequence based on her clinical experience of working with survivors. You may find that reviewing the stages offers direction and hope or resonates with your own experiences so far.
The first stage of this model stresses the importance for the survivor to gain a sense of physical safety and stability. First and foremost, this will mean finding a safe place to live (where necessary and possible), ending any abusive relationships, and starting to engage with a counsellor, therapist or other safe and supportive person.
Learning to feel safe in your body can come in many ways, typically any type of exercise and/or relaxation techniques (such as yoga, meditation, trauma-release exercises, visualisations, mindfulness or listening to music). What is important is that you choose what feels right to you and that it feels comfortable and enjoyable to you. Learning to name your feelings can also be part of this stage.
The second stage typically involves work with your therapist or supportive person to connect to, normalise and feel the feelings you have long pushed aside. You should never feel pressured to say out loud what happened to you in the past. While many survivors experience a sense of relief when they do, others may not yet—or never—be ready to do so. Only you know when the time is right to disclose details of the abuse.
Recognising that the abuse you suffered is something that happened to you in the past but does not define you as a person is a crucial part of this second stage. Many survivors find it difficult to recognise and acknowledge their incredible strength, resilience and adaptability they used to survive as well as many other skills and competencies that they never had the chance to use. The second stage therefore may involve a review of thinking and behaviour that kept you safe and worked very well in the past but that may no longer serve you or even harm you in the present – for example any type of addictions, dissociation, anger, or always putting others’ needs before yours. You can then start identifying healthier ways to reduce stress and tolerate uncomfortable feelings.
The third stage of recovery typically involves moving into a life that is no longer dominated by memories or feelings linked to the abuse. You may feel triggered less frequently and intensely, develop a stronger sense of self, set and pursue personal goals, feel less threatened by relationships and intimacy, and start accepting healthy challenges.
Few people ever progress through these stages in a straight line. There is almost always overlap that may feel like taking two steps forward, one step back. New life events, particularly stressful milestones such as marriage or divorce, birth or death, illness or retirement, moving to a new house or relocating to another country, may set off a new wave of post-traumatic stress symptoms. But as you progress in your recovery journey you have new skills and tools that will help you through challenges and you will find that any setbacks will feel less intense and are shorter than they used to be. Everything you experience are normal responses that are only to be expected. You are human!
I am struggling with pregnancy, birth or early motherhood. How can I make it less difficult for me?
As a survivor of abuse, you might find that you feel unhappy or unsafe about being pregnant. For example, having to ‘share’ your body and not being in control of it can be triggering, the birth ahead and motherhood itself can feel scary, or perhaps you didn’t even want to be pregnant in the first place.
You might also find that you feel unusual sensations such as unsafe, spaced out, hyper-alert, angry, strangely disinterested or even ‘out of your body’ when you have to visit the midwife or any other maternity health care providers (sometimes especially during physical examinations). You may feel upset, confused, angry and exhausted after your appointments too.
The birth ahead may be worrying, as often the parts of your body which are active in birth are the same as were abused in the past.
The thought of strangers around during such an intimate time can be very uncomfortable too.
Some women feel nervous about becoming a mother, as perhaps you feel your abuse history might affect your relationship with your new baby.
You might want to breastfeed, but find the idea challenging.
These are all very normal responses for survivors.
There are several things you can do to help prepare for your midwife and consultant appointments, and for birth and new motherhood:
* Take a friend with you to your clinical visits.
* Make a list of things you want to ask before you get to any appointments.
* Create a birth plan which includes some ideas of ways in which you might feel safer and more comfortable.
* Let your midwives know about your history (only if it feels right to do so) so that they can support you and then make sure that this information is relayed to all your labour ward / homebirth teams, by asking for a note to be added to maternity papers.
* Find who your local breastfeeding peer supporters / where your breastfeeding support groups are, ahead of time.
* Choose a local friend who is someone you really trust and ask her to be your birth partner.
* Choose a local friend who is already a mum and is breastfeeding/has breastfed and ask her to be your support person.
You might also benefit from a Doula. A Doula is trained to support you during pregnancy, birth and in new parenthood, but is not medical or clinical.
Doulas provide information, support and encouragement sensitively and without judgement. Doulas can help you write a birth plan, feel safe and empowered during labour and help you to find your feet as a new mother.
You can find more about Doulas at www.doula.org.uk.
If you are in financial hardship, voluntary Doula care is provided by ‘Doulas Without Borders’. You can apply for this at www.doulaswithoutborders.com
Doulas Without Borders are experienced and trained Doulas who can:
* Help you to identify your potential triggers in labour and birth, and then collaborate with you to create helpful strategies for your birth plan.
* Support and empower you towards creating a safe birthing environment.
* Listen to your concerns and support you in having a calm and loving experience of birth and early motherhood.
* Support you with any feeding issues.
* Help you to find other support services.
I feel overwhelmed by emotions and harm myself. What can I do to stop?
As with all things that cause us distress, it is crucial that we understand what is at the root of it. If you are reading this on the NAPAC website, it is safe to assume that you are already aware of the connection between your self-harming behaviour and the abuse and/or neglect you suffered as a child. Healing and recovery requires facing up to and feeling the feelings associated with past traumatic experiences, but this takes time and coping mechanisms play a part in the process.
Self-harm stops or reduces the impact of overwhelming feelings for a short time. It is often triggered by stress, some type of reminder of a painful experience, or by flashbacks. Like any other harmful coping mechanism, it causes negative consequences and can become addictive over time.
However, replacing a harmful coping mechanism with a less harmful or outright healthy one needs to be done gradually. In fact, stopping a coping mechanism abruptly can in itself be harmful and set us up for failure.
Many people who call our Support Line ask for practical tools that can help them replace self-harming behaviours with alternatives over time.
The key to this approach is to disrupt your brain’s expectation of what will happen next when you are in distress. Replacing self-harm with different but equally effective behaviours will help achieve this. The following are suggestions that have proven helpful to some survivors. You may be able to think of many other creative approaches. As always, coping strategies are as unique as we are.
Start with what might feel the most manageable alternative. Don’t deprive yourself of the short-term relief that self-harm brings but instead postpone it for a brief period. Research has shown that if you can hold off for 15 minutes, an urge (any urge) is much more likely to pass. In those 15 minutes, remind yourself that you are in charge of you. Distract yourself with anything that feels easy and works for you – for example, watching TV, doing the dishes, texting a friend or similar. Every time you want to self-harm but didn’t because you waited, write it down so you can track your progress. Reward yourself in a healthy way each time you succeed.
If you can only manage a few minutes in the beginning, try to focus on what you feel in that brief time. You will still have made a small step towards progress.
Physical action works wonders when trying to deal with overwhelming anxiety, frustration or fear. When triggered into “fight” or “flight” response by memories or thoughts (rather than a real threat in the here and now) our brain still needs to receive the signal that we successfully escaped or fended off a threat so that the nervous system can calm down again. You can trick the brain by punching pillows, ripping up papers, cutting up plastic bottles, digging up soil, yelling, howling, jumping, kicking, running on the spot as fast as you can, breaking wooden sticks or coming up with any other forceful activity that helps you feel empowered.
When sadness, despair or abandonment are the overwhelming feelings, even the smallest act of self-care can help. Hiding under a big heavy cover, hugging a pillow or cuddly toy, smelling your favourite smell, giving yourself permission to cry, playing your favourite song – such approaches will bring relief because they will signal safety to your nervous system, so it can calm down again. Some survivors create their own little self-soothing box with things that feel comforting to them. As a general rule, to sooth yourself, do the opposite of what triggered you. Taking care of yourself in this way also goes a long way to reduce the shame and guilt that often accompanies or follows distress. The ultimate goal is to become your own safe space.
Change your routines and/or surroundings.
Self-harming and many other coping mechanisms thrive on repetition. If you typically engage in self-harm at a particular time of the day, in a particular place, or under a particular circumstance, change your routine and/or setting and get involved in other activities, ideally well before you know the urge is likely to occur. When done consistently, this slowly makes real physical changes in your brain that will reduce your urge to self-harm.
Letting go of control
For anyone struggling with a history of abuse or other trauma, the idea of letting go of control may feel almost impossible. Self-harm, like many other coping mechanisms, gives survivors a sense of control over their bodies – the very control they lost as children. However, as adults, we have more power than we imagine and so we can let go of control in small steps. Practice with a situation where the outcome doesn’t much matter: step out of the way when someone walks towards you on a crowded pavement; allow someone to claim the space ahead of you when waiting in a queue. Whenever you feel you can surrender something that doesn’t come at a high cost to you, do so. It will lay the foundation for letting go of control on bigger issues. As often as you can, practice putting your mental focus on the things that you can change rather than those that are out of your control.
It may sound too simple, but conscious breathing—focusing all your attention on taking deep breaths and exhaling slowly into your belly—is by far the quickest way to calm your nervous system. By breathing consciously, our brain receives the signal that any threat has passed, and it is safe for the nervous system to switch off the “fight”, “flight” or “freeze” response and return to calm. The more often you get into the habit to connect to your breath, the more you will benefit longer-term.
 Chapman, A.L., Gratz, K.L. (2009). Freedom from Self-Harm. Overcoming Self-Injury with Skills from DBT and Other Treatments. Oakland, CA: New Harbinger Publications.