Patients abused as children have often had their boundaries violated. All workers and practitioners engaging with survivors, including GPs, need to model clear boundaries. They need to do what they can to make their patients feel and be safe and this means being very respectful of the patient’s physical and emotional space. Should they inadvertently intrude on their patient’s boundaries, they may replicate aspects of prior abuse and this can be re-traumatising for survivors. Maintaining the role as a GP while the patient seeks help from the counsellor, psychologist or psychiatrist further models good boundaries and helps provide the comprehensive model of care many survivors need.
GPs can make an important contribution, but may not always be able to provide everything the patient needs. Sometimes they will see patients who are in counselling or who are in need of therapeutic support but are unable or unprepared to access it. Either way, patients with a history of child abuse are likely to be facing a number of challenges and will often require support. A listening empathic ear, respect, and validation coupled with a sense of hope and optimism for future recovery are invaluable.
Keep in mind that resources will vary from one area to another and it is often difficult to find sufficient, adequate or appropriate resources. Information from the ASCA website or ASCA professional support line on 1300 675 380 may be of assistance.
Referrals could be to:
- another GP with training and experience in supporting adult survivors
- a psychologist or psychotherapist with experience and training in working with adult survivors
- an appropriately trained and experienced social worker or counsellor
- a sexual assault service, if it is resourced to see patients who have experienced childhood sexual assault
- a psychiatrist with experience and expertise in working with adult survivors.
The ASCA professional support line has a referral database of practitioners and agencies with expertise and experience for working with adult survivors of child abuse.
It is important to check with the patient whether the gender of the therapist is of concern to them and if so, which gender they would prefer to see. It is ideal to provide a choice of referrals and give the patient the option of returning should the referral not be suitable. It is also important to offer to continue to see the patient in the role of GP while the patient is in counselling/therapy.
The following are two case studies that illustrate these principles
Case study: John
John, aged 35, presents to his GP with his wife, Judy and 5-month-old son, James. Judy says that she has been asking John to see a doctor for some time as she is worried about his anxiety. He has seen a locum doctor who prescribed benzodiazepine. John found the medication helped with symptoms but made him feel sluggish. He has also found over the past few weeks that he needs to take more to get the same effect and he feels more unwell when he doesn’t take it. Judy says, ‘I don’t like him taking the medication, it seems to make him more withdrawn and unhappy.’
John is reluctant to talk, but with encouragement from Judy says that he is really stressed at work. His job as a computer analyst has always been busy, but lately he is feeling very overwhelmed and is worried he is not performing well.
He is irritable and finds himself ‘flying off the handle’ more easily. His colleagues at work have asked him a few times if he is okay. He has had some disagreements with his boss. He says that, while he has generally interacted well with his boss, he is aware that the boss isn’t a very good manager and that this has recently been bothering him. He is finding it difficult to get to work in the mornings and dreads getting out of bed.
Judy says she has noticed that he is not sleeping well and he agrees, saying that he is having difficulties getting off to sleep and wakes early, feeling tired. He has bad dreams that often wake him and he then finds it hard to get back to sleep. These symptoms started about 4–5 months ago.
John’s father had a problem with alcohol and was violent towards John’s mother. He left the family home when John was 9 years old. John has had little contact with him since. John appears to become increasingly distressed through the consult and says: ‘There was some stuff that happened to me when I was young. I thought I’d dealt with it but it seems to be haunting me now. My mum did her best but she couldn’t keep me safe and my dad didn’t care enough.’ John says he worries about his son and fears for his safety. He says, ‘James just seems so small and I’m worried I won’t be able to protect him from the world.’
Over a number of consultations John discloses that he was sexually assaulted as a child over a number of months by a neighbour. This abuse only stopped when John and his mother moved house. Despite his early childhood trauma, John appeared to manage life well, completing his tertiary education, working full time and creating a close nurturing relationship with his wife and close friends. The life stage of becoming a father appears to have triggered symptoms consistent with PTSD related to his past trauma. The prescription of benzodiazepine, while providing some short-term relief, has led to dependence and tolerance and it does not treat the underlying issue and cause of the distress.
This case illustrates a scenario in which the effects of past abuse appear to have been triggered by having a child. This has presented as nightmares and anxiety. John seems also to be having some problems with authority figures – his boss at work, for example – and this would be consistent, as abuse occurs in situations of inherent power imbalance. The benzodiazepine, while providing short-term symptom relief for his anxiety, has not addressed the true cause for the symptoms, which, at the time was not identified. John is ultimately helped over a period of time through sessions with a psychologist. As he works through his abuse issues he comes to understand what was contributing to his anxiety and how it was linked to the birth of his son. He is able to stop using the benzodiazepines.
Case study: Susan
Susan, 21 years of age and living in a country town, presents to your practice requesting a Pap test. While taking a history, Susan reveals that she is dissatisfied with her sexual relationship; she doesn’t enjoy sex, feels uncomfortable and finds it very hard to relax. She asks you if this is normal. Her reason for wanting a Pap test is that she has been talking with her friends about women’s issues and they seemed to think that regular tests were a good idea. Although she is not sexually active at the moment she says she would feel happier to have a full check-up.
On examination, Susan is extremely tense and performing the Pap test is difficult. You stop the examination, coming to the conclusion that to proceed would be detrimental to Susan. Susan is upset and once she is dressed you reflect back to her that the examination was anxiety provoking. She calms down and says that she will come back in a couple of weeks now she knows what is involved. Before she leaves you inquire about any past unpleasant sexual experiences. She repeats that she doesn’t enjoy sex but that she can’t remember anything of a frightening or threatening nature.
One week later Susan reappears at your surgery saying she has been disturbed since the attempted Pap test. She is having strange dreams and has a feeling that something happened when she was younger. She grew up on a small property out of town. After some discussion she says she thinks something happened with her older brother and some of his friends but that the memories are unclear. She is obviously distressed.
Most likely diagnosis:
- sexual dysfunction
- child sexual abuse.
Together you explore the options – for example, counselling/therapy (individual or group) and whether she wants to see a counsellor at the sexual assault centre or an allied health practitioner with expertise and experience in supporting patients with past abuse. Should she not be able to see a counsellor/therapist immediately, it would be important to see her regularly in the interim. You could discuss strategies that might provide some relief to her sleep disturbance; explore her diet, exercise and self-care and assess her supports by way of friends and relatives, encouraging her to reach out to those she trusts and with whom she feels safe. If you were concerned that she was deeply depressed and/or suicidal, you could consider contacting the local crisis team or psychiatric help.
Susan opts to go and see a counsellor at the local sexual assault service. As the waiting period is 3 months you offer to see Susan on a weekly basis for support. She agrees to this arrangement and you are able to work with her to help her feel safe and improve her capacity for self-care. Nine months later she comes to see you for a Pap test. Although Susan is slightly tense, she can relax sufficiently for the examination to be performed successfully. Susan is relieved and says that in counselling she has been feeling that she is making good progress and being able to have a Pap smear is indicative of her progress as well. She thanks you for your involvement.