Las nociones de género: Entre la realidad e imposición

The issue of referring survivors on insensitively upon disclosure of CSA was raised spontaneously by nearly half of the mental health professionals interviewed. Their previous clients had related how this had occurred, and the resultant negative reinforcing message it had sent to them.

Referring survivors on to CASA or another mental health professional was considered common practice once the survivor disclosed CSA to their current

provider. However, this was viewed as both negative and positive for client welfare. On the negative side, referring was viewed as detrimental, as a positive therapeutic relationship had been established to promote disclosure. MHP 3 stated:

… And then have to build up trust with somebody else! I mean, people who have been sexually assaulted as children have a very hard time trusting people… I think they have a hard time trusting [professionals], and then to be shunted off to somebody else is not appropriate…

Gina described the difficulties she faced when she was no longer consulting with a mental health professional she built a strong rapport and therapeutic

relationship with. Gina described this loss as “really painful” and that nobody could “fill [her] shoes”. This experience left her feeling disappointed and

demoralised with the prospect of having to establish rapport with somebody new, as well as having to retell her story.

While it could be difficult for any client to lose a valued mental health professional, this may be especially so for survivors of childhood abuse. CSA survivors may already expect betrayal and abandonment, as well as difficulties establishing trust. Having that connection discontinued at the mental health

professional’s behest could reinforce the survivor’s core belief that others are not to be trusted and will eventually abandon them.

Many mental health professionals believed that insensitively referring the survivor to another professional or service conveyed the message that the issue of CSA was too great a problem, leading to clients feeling like a “hot potato”.

Now what message does that send? That you’re so stuffed and what you’re telling me is so terrible that I can’t deal with it? … You’ve got to be careful about a really quick handball. – MHP 2, and,

Some of the men I had seen who had disclosed [to a professional] almost had a shaming, or felt like the person couldn’t handle it, or they were too quickly referred on, or they felt like a ‘hot potato’, and they felt [the professional] couldn’t deal with it… - MHP 6.

Usual practice dictates that only one mental health professional is seen at a time so ‘splitting’ does not occur, as MHP 9 explains:

When you start seeing two people, there’s a dynamic, a split… so I don’t think that’s therapeutically helpful… I think you’re recreating a split… I’ve tried to explain to clients before why they should go back to the initial person, or that they actually consider to find somebody who can do both, rather than separate out the depression and relationship issues, but actually somebody who can hold the lot…

Another mental health professional agreed, stating it was “unethical” for a mental health professional to continue receiving payment for CBT treatment for particular mental health symptoms, while also referring the client to a service to work with the underlying issues for such symptoms.

Published literature has not highlighted the issue of appropriate referral. McGregor et al.’s (2006) study indicted that some mental health professionals terminate therapy upon learning about the CSA experience, but it was identified they were not referred on to anybody else. This theme of insensitively referring on was an unexpected and important finding that could have implications for practice.

Despite the opinion that referring on can be detrimental, mental health professionals are guided by the principle to ‘do no harm’ and work within their realm of expertise. Specifically, the Australian Psychological Society’s Code of Ethics (2007) states that psychologists ‘only provide psychological services, within

the boundaries of their professional competence’, including, ‘working within the limits of their education, training, supervised experience and appropriate

professional experience’ (Section B.1.2). An “ideal” solution to circumvent these issues and work ethically was cited, where the current mental health professional could work alongside a service such as CASA for secondary consultation. As survivors’ issues cannot usually be clearly and neatly delineated between ‘sexual assault’ issues and ‘mental health’ issues, the survivor is then able to address both simultaneously. MHP 2, who works at a CASA explains:

There are many situations where we will provide secondary consultations and utilise that really good therapeutic relationship. If you’ve worked with

somebody for years and you’ve got great rapport with them, why not use that? This sentiment was demonstrated by an example provided by MHP 9:

We thought she [the mental health professional] had a good relationship with her client and they had been working together for a while, so it would be almost crazy to interrupt that to tackle this issue… [the professional] was great… she really welcomed the idea of receiving that service and support and

consultation… I don’t know how experienced she was, but for me that [situation] was ideal, the way to go…

According to mental health professionals, one did not have to be an expert in the field of sexual violence in order to work with CSA. In fact, Gina noted that despite her current mental health professional not being an expert in CSA, she was learning about complex trauma and relaying newfound knowledge to her. Gina viewed this approach as highly collaborative and respectful in that the professional did not assume the role of ‘expert’, and shared the mutual learning process.

As suggested by interviewed professionals, seeking consultation or supervision with knowledgeable individuals or agencies is considered an ideal approach to maintaining a therapeutic alliance and assisting the client. However, if

the mental health professional does not desire to learn about, or work with trauma, or believes their own personal beliefs or trauma experiences could be detrimental to working with the survivor, then it is recommended that referral be done sensitively. This could include being as collaborative as possible, being transparent about their level of expertise, and working with the survivor to find the best possible

professional. These practices may reduce the survivor’s feelings of betrayal, abandonment and shame.

An additional referral issue was raised by two professionals, where offenders of violence, who were also CSA survivors, were unable to find a professional or relevant agency to work with them on issues associated with the abuse. MHP 1, a forensic psychologist, noted:

[Some of my clients] were sexual offenders and quite often when they had a history of CSA, they found it really hard to find someone that would provide a service, because they were a perpetrator as well… I don’t think it was only CASA [but] a lot of psychologists and probably other professionals in lots of areas kind of freak out about it.

MHP 5, whose two male clients had both experienced histories of CSA and committed crimes against women, stated she “didn’t even bother” to contact CASA about referral as she was aware they did not work with perpetrators of violence, even if they were victims themselves. This issue was an unexpected theme found by the current study. There is a general lack of available published literature that highlights this dilemma, due to much research being framed within a feminist framework.