Survivors of child sexual abuse have a lot to deal with. Betrayal of trust, sexual confusion, manipulation, violation of the body, secrecy, deceit, emotional ambivalence, loss of autonomy, dissociation from the body, shame, guilt, often pain, and often some degree of sexual pleasure can all be present in a single instance of abuse, or over the course of an abusive relationship. Many of these elements are at best difficult and at worst intolerable even in the context of relations between consenting adults. To lay this complex of confusion on a child, or even on a young adult in a dependent or protected relationship, is manifestly unfair. The younger the survivors-and the more subject to other vulnerabilities-the likelier that the burden of abuse gets "hard coded" into children's still-developing "firmware:" the base patterns of perception, understanding, and action they carry into the more normal ages for sexual development and exploration and on into adult life. Something's Got to Give When inherently strong and inherently conflicting thoughts and emotions are bound up with betrayal and trauma, they may become unbearable. A common coping mechanism is "dissociation," where the abused child's sense of self seems to separate or dissociate itself from what is being done to the body. Dissociation, denial, and flights into fantasy in order to escape an unbearable reality are dramatic examples of emergency measures survivors instinctively take to ensure not only their survival at the moment of trauma, but their ability to function in a world that no longer makes sense, and where the rules are no longer knowable. (As we have seen in public cases of serial or institutional abuse, denial and fantasy can also be at work in an abuser's marriage and family, professional environment, and community.) Hidden Effects of Trauma Less dramatically and visibly, the mind is capable of thousands of tricks to try to reconcile the irreconcilable. These can include misperceptions based on irrational thought patterns so deeply ingrained that they are no longer consciously thought, and never re-examined. They may include emotions and sensations that usually help us cope or give us pleasure, which have been so deeply entwined with pain and shame that the good and useful get buried along with the scary and bad. These emergency measures become routine, even when we are not facing emergencies, but the little disturbances of humankind. Abuse survivors often show hypervigilance and exaggerated startle responses typical of post-traumatic stress disorder (PTSD). Constant watchfulness, sensitivity, and overreaction complicate our lives, adding objective stress to the chronic distress of never again being sure that the ground will not shift under us and knock us flat on our backs, or have us once more eating dirt. Why Therapy? It is all but impossible, acting on our own, to unpack what the survival instinct has hidden from view. Therapy offers both children and adult survivors trained, objective help in unraveling those psychic tangles. Especially for child survivors-although some of the same dynamics may apply to adults-the therapist's office may be the only safe space; the therapist's ear may be the only one that listens; the therapist's responses may be the only ones not tinged with judgment, accusation, or conflict. Therapy for child sexual abuse should have a simple, transparent agenda: \tProvide a safe space for survivors to confront the truth \tOffer perspective and specific tools to teach survivors how to cope with the fact and the aftermath of abuse \tIn the case of ongoing abuse, cooperate with civil authorities to insure survivors' safety \tIn the case of past abuse, help ensure that survivors act in our own best interests in deciding whether to pursue prosecuting the abuser Early therapeutic intervention can help identify destructive patterns before they become hardened by repetition, and can help prepare a child for sexual adulthood and parenthood that neither replicate patterns of abuse nor fearfully avoid the physical affection all children need. Early untangling of the truth of abuse cases helps timely and effective prosecution of a criminal offender, and may prevent untold anguish by preventing future crimes. How Does a Survivor Work With a Therapist? Psychotherapists use a variety of techniques-"talk therapy," cognitive and behavioral tools, and other methods-to reach the goals of confronting the truth, ensuring our safety, and learning to get on with our lives. Each of these options are often tried or discussed with a patient at different points in the therapeutic process, depending on the preferred practices of the therapist, and what the patient finds most helpful. Therapists of abuse survivors are well aware of our special need to reclaim our autonomy: our ability to act independently, on our own behalf, for our own best good. This may include questioning the goals and means of our therapy, expressing and examining our discomfort with any part of what may at times be a difficult, distressing process. Your therapist should be happy to see you acting in your own best interest, and will help you work through your options for a successful outcome-whether that means staying the course, trying alternate methods, or recommending a colleague who may be better suited to your needs. After all, the goal of psychotherapy includes ultimately growing beyond needing our therapists.