Abuse – an NHS self help guide

Introduction 
What is child abuse? 
What are some of the signs a child shows when he or she has been abused? 
What are the longer-term effects of being abused as a child? 
Beginning to overcome the effects of abuse 
Is there further help available? 
Useful organisations 
Useful books and websites 
Mindfulness downloads 
Relaxation downloads 
References 
Rate this guide 

“I think I’m going mad, my moods are up and down all the time, I can’t control them. I sometimes feel so angry that I have to hurt myself to get rid of the feelings…”

“I have memories coming into my mind all the time of what happened to me when I was a child. I can’t understand why. I’ve never thought about those things until now… I don’t like what I can remember, it fills me full of fear, I can’t believe someone would do that to a child…”

“Relationships are a disaster area for me. I can’t trust anyone… the same old pattern occurs again and again, especially with men. It is as if my dad was still around and still harming me. I even react the same, always trying to please and pretending there is nothing wrong … what is it about me that causes this…”?

“I keep out of other people’s way, I’ve learned that is safer, but I feel empty and full of pain…”

“I know I don’t want to face what has happened in my life so I don’t. I drink, take drugs, binge and starve. All of this hides what has happened…” “I can never say no to anyone, they can walk all over me, do and say what they want. It’s only later that I begin to feel angry and it’s usually at myself…”

“I sometimes think I’m completely bad and rotten, then at other times I think no it’s not me, it’s them…”

People who have been abused as children experience many varied feelings. The descriptions above are just a few examples of the distress people may be left with, though having such feelings does not necessarily mean that you have been abused.

This booklet is written by people who have experienced abuse and by psychologists and others who work with them to try and help them overcome the effects of what has happened. It aims to help you to begin to:
1. Understand the effects of childhood abuse, both at the time and its impact on you now.
2. Explore ways in which you may begin to overcome the effects of the abuse, and where you may get further help.

We hope you find the booklet helpful and would be very grateful for any feedback from you on its content and anything you feel we have left out. There is a lot of information in this booklet and it may be helpful to read it several times, or to read it a bit at a time, to get the most from it.

No two people will react in exactly the same way to having been abused and with this in mind different parts of the booklet may help different people. Please choose what you feel is helpful.

It is also important to note that many people who have not been abused may also experience the distressing thoughts, symptoms, feelings and behaviour described in the booklet.

What is child abuse?

Abuse of children is something which has happened over the generations irrespective of race, gender, class or culture. Only recently have people recognised that it happens and talked about it a little more openly. Society still has difficulty in accepting that child abuse is widespread, so it often goes unrecognised.

There are different ways that children are abused. All of these are serious and affect the child even if the child may not seem to be distressed at the time.

Neglect – is where the parent or carer does not provide for the basic needs of a child. This can mean leaving a child alone when he or she is too young (or leaving him or her with brothers or sisters who themselves are not old enough to manage). This can leave the child in dangerous situations. It can mean not looking after children when they are ill or not keeping them clean and warm with a roof over their head. Neglect has serious long-term effects on children.

Emotional neglect – this term is used when parents don’t give kind attention, love and comfort to their child. They may appear uninterested in the child, and show no affection or care. This can have serious consequences for the emotional development of that child.

Physical abuse – when a child is subjected to violence such as beating, punching, burning, being bitten, thrown around or kicked they have been physically abused. This is dangerous in the short-term for the child who may be in pain or whose life may be at risk. It is also dangerous in the long-term as it leaves emotional scars and fears which are also very distressing.

Sexual abuse – a child faced with any kind of sexual contact by any other person may have been sexually abused. The abuse can involve forced intercourse, or other sexual acts, it can involve touching inappropriately. It may be a child’s presence or involvement with the sexual acts of others, or being shown pornographic pictures or films. This form of abuse may involve family members, family friends, teachers, carers or strangers. It may have happened only once, for a short period of time or may have happened over a long time. Any sexual abuse can lead to serious distress for the child at the time and/or later in life.

Other forms of abuse can be in the form of mental cruelty such as continuous name-calling or humiliation and excessively harsh punishments.

Facing the pain of abuse

It is painful to face the effects that the abuse may have had on you both now and in the past. Here are some examples of how some people respond to childhood abuse.

• Many people who have experienced abuse cannot recall large periods of their childhood.
• Some people can recall what happened but have not linked the abuse to their current difficulties and distress.
• Some people recall a general unhappiness but have partial memories of abusive events.
• People who can remember much of what has happened may try to avoid thinking about it.

It is common for people to try not to think about the abuse because it is such a painful experience.

Do any of these apply to you?

• Do you try to excuse it?
“It was just his way of showing love”. “She had too much stress, that is what caused her outbursts”.

• Do you make light of it or play it down?
“He bruised me but it didn’t go any further”. “I was only touched, it wasn’t full sexual intercourse”.

• Do you blame yourself?
“It was my fault; I must have done something wrong…” “I sometimes went to him for a cuddle ….”

It may help you to read the following sections to understand more about abuse.

What are some of the signs a child shows when he or she has been abused?

Children who are being abused may show signs of distress at home and in school. These signs are not always noticed by others and the child may even be labelled difficult, disruptive or unwell.

Did you show any of the following signs of distress when you were a child?

• Eating problems – overeating, starving, bingeing and vomiting etc.
• Toilet problems – soiling, bedwetting, etc.
• Behaviour changes – becoming disruptive or antisocial, stealing, tantrums, not mixing with others.
• Schooling difficulties – underachievement, truancy, overworking at school.
• Emotional problems – fears, phobias, obsessions, nightmares.
• Self-harm – suicide and self-harm attempts, alcohol or drug misuse.
• Sexual behaviour – sexual behaviour that is not age appropriate.
• Physical problems – frequent illnesses, stomach pains, headaches, urinary infections, genital pain, bruising, broken bones.

These signs do not always mean abuse has occurred. They can be found in children who have not been maltreated or abused. But they are sometimes apparent in children who have been abused, or are unhappy for some other reason.

If you feel you were abused as a child it may help to try and recall how those around you responded to the signs you displayed. Please only complete if you feel this would help you.

Who was around?

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How did they respond?

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What are the longer-term effects of being abused as a child?

People respond in different ways to having been abused as children. The following descriptions are only examples of some of the possible longer-term effects of abuse.

Relationships

Adults who were abused as children have often been let down by those they trust most. Trust can become a major issue which can prevent them from having successful adult relationships. People who were abused sometimes feel they cannot rely on their own judgements about others. It is easy to see that because they have not been able to rely on those who were meant to care for them as children they feel afraid of trusting those around them in adult life. This can lead to loneliness and isolation. It can lead to fear of strangers or crowds of people.

Because many people who have been abused feel so unlovable they feel they cannot take the risk of letting others get to know them.

Intimate relationships can also be a problem. For people who have been sexually abused sexual difficulties may occur. This can include fear of sex, confusion about sexuality, no interest in sex and obsessions relating to sex. If people have been physically abused they may feel tense fearful or angry in response to affectionate physical contact.

Survivors of abuse can sometimes find themselves getting into unhelpful relationship patterns. This can involve becoming the perfect carer, rescuer, or it may be that they allow themselves to stay in other abusive relationships. Some survivors may also have problems with sexual promiscuity relating to their deep need to please others. People may also feel confused about their sexual identity.

Feelings of self-worth

Because they have not always been treated with the love and respect they deserve, many people who have been abused do not learn to feel love and respect for themselves. This often includes a strong sense of being bad or unlovable in some way. Some people may have been told that they were no good and may feel not as good as others.

Self-esteem and self-confidence can be very low. This may lead to difficulties in saying no to people, problems in making decisions and letting others take advantage.

Emotions

Survivors of abuse describe a range of difficult emotions that they have to try to manage. Many people feel very depressed at times. This can be so severe that they sometimes think about suicide. Other people may find themselves on an emotional roller coaster with massive mood swings. Shame and guilt are common emotions that often come with depression. Some people experience anxiety, fear, phobias, nightmares and may have problems sleeping.

Aggressive outbursts and angry feelings can also occur. It is not always obvious to the person what the anger is about.

Though it is not surprising that people should have a lot of anger, it is sometimes as if the anger is just bursting to get out. They may feel guilty and ashamed after an outburst.

Eating

Many people who have been abused have problems with food and eating and may feel unhappy about the way they look. This may lead to compulsive eating, bingeing and vomiting, or starving.

Flashbacks and nightmares

Many people who have been abused experience flashbacks and nightmares in their adult life. Flashbacks are very clear memories which may make the person feel they are reliving the abuse. Nightmares can be about what happened or can be about only parts or it, such as being trapped or chased. Both flashbacks and nightmares can be very distressing.

Achievement

Not surprisingly being abused does seem to have an impact on achievement and performance. Many people set themselves harsh goals and high performance standards. For them whatever they do or achieve is not good enough. Other people who have been abused do the opposite. They expect nothing of themselves and predict failure. They fear that achievement will draw attention to themselves. They expect that this attention will have bad results such as others not liking them. Some people have behaved in a way when they were young that they later regret, such as petty crime or other bad behaviours and this may lead to feelings of shame and self hatred.

Self-harm

Some people who have been abused as children harm themselves in some way. This can be by attempting suicide, or it may be in other ways. Some cut, burn or injure themselves. Others drink to excess or abuse drugs. Sometimes people place themselves in risky situations where they may be harmed by others. The reasons for this self-harm are complex but often it is used to manage horrible feelings.

Another booklet in this series gives more detailed information on self-harm.

People with a history of abuse may also have worse physical health than others. This includes a range of disorders including chronic pain, stomach problems and irritable bowel syndrome.

We hope that up to now the booklet has helped you understand abuse a little more and in particular to begin to see the distressing effects that it can have on people’s lives.

The next sections will explore ways in which you may begin or continue to overcome the effects of abuse that happened in your childhood.

3. Beginning to overcome the effects of abuse

Keeping safe

The most important first step in beginning to overcome the effects of abuse is to make sure you are now safe.

Look at the following list of questions. If you are answering yes to any of them then we recommend that you should talk to your doctor or therapist.

• Do you have impulses to harm yourself?
• Does someone close to you harm or threaten you?
• Have you attempted suicide?
• Have you plans to kill yourself?
• Do you find yourself in unsafe situations?
• Do you feel overcome by memories, thoughts and feelings or have you felt you have become ‘out of touch with reality’?
• Does someone close to you often involve you in dangerous or illegal situations?

If you have impulses to self-harm our booklet Self-Harm may be helpful to you.

Relationships

In the last section we asked you to think about how your own relationships may have been affected by abuse. It may be that you have found yourself in repetitive relationship patterns for example:
• You always end up rescuing or caring for others in a way that is not helpful to you.
• You cut yourself off from others.
• You find you can’t say no – you let others do what they like to you.
• You find ways of numbing the pain of relationships by drink or drugs or self-harm.
• Others are abusive to you.

It may help to try and gradually change the ways in which you are with others. You will also need to consider your own self-esteem in making these changes.

If you are always rescuing or caring for others, try to ask for your own needs to be met as well. Allow others to give to you. You may be only choosing needy people as friends; try to have a mix of friendships. Do you have thoughts like this, “I will be rejected if I don’t give to everyone” – if “yes” challenge them. It can help to have a supportive circle of friends around you.

If you say yes all the time and others end up taking advantage of you, learn to say no. Remember that you have rights too. Setting a limit can protect you from being used or let down by others. If you feel you are overly promiscuous, then try to understand the reasons for this and try to set boundaries and keep yourself safe.

If you end up numbing the pain of relationships by drink or drugs or other methods, take time to explore what tends to hurt you in these relationships. Look for patterns – keep boundaries, get your needs met.

If you feel you may be in an abusive relationship the following questions may help you to think about this:
• Does your partner physically harm you?
• Does your partner verbally abuse you using threats, name calling, humiliation?
• Does your partner try and control you?
• Are you afraid of your partner?
• Has your partner forced you to have sex?

If your answer is “Yes” to these questions then it would be helpful to plan how to stop this situation. This may be by leaving the relationship or changing the relationship to stop the abusive behaviour.

If you are having difficulty with these changes it may help to seek the support of a professional worker or support group to move forward. There is also a booklet in this series on Domestic Abuse which may be helpful.

Low self-esteem or self worth

In the previous section we asked you to consider how your self-esteem has been affected by the abuse. This low self-esteem can lead to:
• Difficulties in trusting your own judgement.
• Feeling you can’t express your views.
• Staying in bad relationships.
• Feeling guilty.
• Hating yourself.
• Being self-critical.
• Overwhelming shame.

There are a number of ways you can begin to tackle low self-esteem:

Remind yourself of this list every day.

Challenge any critical thoughts you have about yourself. Many people who have been abused think:
• “Why me? – I must be bad”.
• “Why didn’t I stop it or tell someone?”

It may help to try and think what you would say to a friend who made similar statements about him or herself. Write down and challenge critical thoughts you often have. For example:

Critical thoughts about yourself
e.g. “There must have been something bad about me… that I was abused…”

Challenge
“No child deserves to be abused”.

If you feel shame and self blame remind yourself of how the behaviour of the abuser put you in to an impossible situation for a child. This may have been by use of threats, control, rewards, secrets and promises of ‘special gifts’.

Accepting yourself
Many people who have been abused have a view of themselves as being bad, but not much recognition of their positive side. They can be critical of their weaknesses but not accept or take credit for strengths. It can be helpful and well balanced to accept both your strengths and weaknesses. Everyone has both. Accepting your own strengths and weaknesses can help you to realise that others are the same.

It can be helpful, realistic and balanced to recognise both the strengths and weaknesses of people around you.

Assertiveness
Learn to become more assertive. Explore options with your therapist, if you have one. It may be possible to go to classes or read up on the topic. Many people who are not assertive feel that if they become more assertive they are being aggressive. Some people move from being passive to having aggressive outbursts. It is important to move from being passive to being firm but assertive.

Passive Assertive Aggressive

This is what we are aiming for

Emotions
Fear, depression, anger and other emotions are all natural reactions to abuse but they can be difficult to manage and many survivors can feel that they are on an emotional roller coaster. It can be difficult to tell what you are feeling at times because the emotions can be mixed up together.

A first step to beginning to manage these emotions is to try and identify what you are feeling and if possible why. Try keeping a diary of thoughts and feelings especially at those times when you are feeling very emotional.

Here is an example:

Day and time – what was
I doing
What I felt like – emotion
What thoughts or pictures
were in my mind.

11pm at home and alone,
following a night out.
Feeling both fear and anger.
I had a memory that came into my mind of my step-father coming into my room. My thoughts now are how could he put me through that…

It can also help to learn ways of self-calming and self-soothing for times when you are feeling very emotional.

Here are some examples of self-calming:
• Relaxing
• Exercising
• Going for a walk
• Reading a book
• Stroking a pet
• Calling a friend
• Listening to music
• Touching something soft/familiar
• Planning a nice event
• Making something
• Practicing slow, deep mindful breathing
• Picturing a pleasant safe place in your mind

Mindful breathing
This is an approach to managing emotions. The goal of mindful breathing is calm, non-judging awareness, allowing thoughts and feelings to come and go without getting caught up in them. The aim is to concentrate only on the present moment, not the past and not the future. Much of our stress is linked to thoughts and feelings about the past and the future. Follow these instructions:

• Sit comfortably, with your eyes closed or lowered and your back straight.
• Bring your attention to your breathing.
• Notice the sensations as your chest and stomach rise with the in-breath, and fall with the out-breath.
• Thoughts will come into your mind, and that’s okay, because that’s just what the mind does. Just notice those thoughts, then bring your attention back to your breathing.
• You can notice sounds, physical feelings, and emotions, and again, just bring your attention back to your breathing.
• Don’t follow those thoughts or feelings, don’t judge yourself for having them, or analyse them in any way. It’s okay for the thoughts to be there. Just notice those thoughts, and let them drift on by; bring your attention back to your breathing.
• Whenever you notice that your attention has drifted off and is becoming caught up in thoughts or feelings, simply note that attention has drifted, and then gently bring the attention back to your breathing.

Thoughts will enter your awareness, and your attention will follow them. No matter how many times this happens, just keep bringing your attention back to your breathing. The more you can practice this exercise the more it will help you to manage stress.

More detailed descriptions of coping with anxiety, depression, anger and other difficulties are available in other self-help booklets in this series.

Flashbacks and nightmares
As described earlier, many people who have been abused experience flashbacks or nightmares. They are a way of fears and memories coming to the surface. They can be very distressing.

The best way to deal with them is for you to begin to take control of them.

For both flashbacks and nightmares (as soon as you wake) try the following approach.

1. Write down every detail of what came into your mind. Do this every time they happen. If you keep writing them down they should begin to go away.

2. Remind yourself that you are now an adult who is safe and no longer in that situation.

3. It can sometimes help to make up a new ending for the memories/pictures that you have in your flashbacks or nightmares. For example some people imagine that the abuser is blocked off behind a metal screen. Others picture themselves as an adult (or some other safe person) coming into the scene to stop the abuse. This can help you to feel more in control of these unpleasant memories.

If you find that you are still struggling with flashbacks and nightmares it may be useful to seek professional help.

Stabilising other areas of your life
If your life is constantly in crisis or chaos it may be helpful to check through and think how you may begin to plan to make it better. We know that people who have experienced abuse in childhood are more likely to have health problems as adults. It is therefore really important to take care of your wellbeing.

The following list may help you to pinpoint target areas (please tick).

Yes
 Health
 Eating
 Drinking alcohol
 Illicit drug use
 Lack of exercise
 Other health problems
 Sex and sexuality
 Money problems
 Legal problems
 Housing problems
 Relationships/family problems
 Work/achievement/education problems
 Other areas: (please state)
…………………………………………………………

It can help to think of as many ways as possible to tackle each problem, then choose one to start with. Tick each off the list as you tackle it.

Is there further help available?

This booklet is designed for you to work through with a doctor or therapist. We hope the suggestions in this booklet have been helpful to you.

The contacts here are all national, but they will be able to give you details of what is available local to you. Your doctor or therapist will also have information about other local services which may be useful.

Useful organisations

• British Association for Counselling and Psychotherapy
Tel: 01455 883 316
www.bacp.co.uk
Offers an information service providing contacts for counselling in England and Wales.
• Childline
Freephone 0800 1111
www.childline.org.uk
Children and young people can contact if they are in trouble or are being abused.
• Citizens Advice Bureau
www.citizensadvice.org.uk
Contact your local office; they can direct you to local groups who can help.
• Healthwatch
www.healthwatch.co.uk
Healthwatch England is the independent consumer champion for health and social care in England. Working with local Healthwatch networks, we ensure that the voices of consumers and those who use services reach the ears of the decision makers.
• Mental Health Matters
Tel: 0191 516 3500
www.mentalhealthmatters.com
A national organisation which provides support and information on employment, housing, community support and psychological services.
• Mind Infoline
Tel: 0300 123 3393
Text: 86463
www.mind.org.uk
Provides information on a range of topics including types of mental distress, where to get help, drug and alternative treatments and advocacy. Also provides details of help and support for people in their own area.
Helpline available Mon – Fri, 9am – 6pm.
• NHS Choices – Your health – your choices
www.nhs.uk
Information about conditions, treatments, local services and healthy lives.
• Rape Crisis Centre
Freephone: 0808 802 9999
www.rapecrisis.org.uk
Email: info@rapecrisis.org.uk
Helpline, support, counselling and information for women and girls who have been raped or sexually assaulted.

• Relate
Helpline: 0300 100 1234
www.relate.org.uk
Help with marital or relationship problems.
• Rethink
Helpline: 0300 5000 927
www.rethink.org
Provides information and a helpline for anyone affected by mental health problems.
• SAFELINE
Helpline: 0808 800 5008
Male Helpline: 0800 800 5005
Young People’s Helpline: 0808 800 5007
Text: 07860 027 573
www.safeline.org.uk
Offers information and support to survivors of abuse.
• Samaritans
Helpline: 116 123
www.samaritans.org
Email: jo@samaritans.org
Freepost RSRB-KKBY-CYJK, PO Box 9090, Stirling, FK8 2SA
Confidential support for anyone in a crisis.
• Survivors UK
Helpline: 020 3598 3898
Text: (SMS) Chat Service 020 3322 1860
www.survivorsuk.org
Email: info@survivorsuk.org
Provide information, support and counselling for men who have been raped or sexually abused.
• Victim Support
Supportline: 0808 1689 111
www.victimsupport.org.uk
Offers support and practical advice to victims of any sort of crime, including sexual abuse.
• Women’s Therapy Centre
Tel: 0207 263 7860
www.womenstherapycentre.co.uk
Email: enquiries@womenstherapycentre.co.uk
Offer individual counselling and groups for women who have been sexually abused.

Useful books and websites

• A source book on child sexual abuse
David Finkelhor
Sage 1986
Offers social welfare workers, clinicians, policy-makers and researchers easy access to the results of a large number of studies, many of which are unpublished or not readily available.
• Adult male survivors of childhood sexual abuse
Kim Etherington
Pitman 1995
Aims to clarify the distinct issues involved in the sexual abuse of male children. Contains accounts from survivors of childhood sexual abuse, ways in which agencies can improve methods of working with survivors, examination of treatment and recovery programmes, and effects of sexual abuse.
• An introduction to coping with childhood trauma
Helen Kennerley
Constable and Robinson Ltd, London 2011
A self help booklet to help adults who have been victims of child sexual abuse to learn coping skills and resilience. This booklet describes the symptoms suffered by victims of child sexual abuse, and shows how these symptoms can be managed. It gives you strategies to deal with stress, mood swings and the challenges in life that seem to be unassailable.
• Breaking free: help for survivors of child sexual abuse
Carolyn Ainscough and Kay Toon
Sheldon Press 2000
A workbook for survivors of sexual abuse; offers to help the reader explore the problems that child sexual abuse often causes survivors in later life.
• Ghosts in the bedroom: a guide for partners of incest survivors
K. Graber
Health Communications 1991
A 12-step approach to help partners of survivors cope with their own feelings, support the recovery of their partner, and solve relationship problems together.
• Overcoming childhood trauma
Helen Kennerley Robinson Publications 2000
This book will help the sufferer understand the links between past trauma and present difficulties and offers ways to gain control over these problems, allowing the individual to deal with intrusive memories, manage mood swings and build better relationships in adulthood.
• Strong at the broken places: overcoming the trauma of childhood abuse
Linda T. Sanford
Virago Press 1991
Combines dedicated research and interviews with victims of childhood abuse and neglect.

Internet sites that survivors of abuse have found useful:
The internet is a source of help but please use with caution as some of the content may be distressing.
• www.metanoia.org/suicide
Part of a larger site, this offers support to people feeling very distressed or suicidal.
• www.ascasupport.org
A site which offers help to people who have experienced abuse. Provides guidance on safety, identifying support networks, resolving relationships.

Mindfulness downloads
• Franticworld.com Mindfulness: Finding Peace in a Frantic World – Free meditations and mindfulness resources.
• www.headspace.com – A free taster of mindfulness, with an opt-in to buy further sessions
• www.freemindfulness.org – A collection of free to download meditations

Relaxation downloads

• http://wellbeing-glasgow.org.uk/audio-resources/
• www.ntw.nhs.uk/ relax.php

References

A full list of references is available on request by emailing pic@ntw.nhs.uk

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