Therapy With Women in Street Prostitution
How can therapy reach out to some of the most vulnerable and excluded women in society? Founded by Pip Hockton in 2005, Street Talk is a charity that takes therapy to women in street prostitution using a pioneering model rooted in Object Relations Theory. In the hope of encouraging others to carry the work forward, Hockton has defined this approach in a new book. As she explains here, the aim is to help women to encounter their own humanity.
Working as a therapist in the NHS, I became aware that those who needed mental health care most were almost entirely excluded. Among the most vulnerable of the people on our streets are women who become trapped in street prostitution. In 2005, I began working with those women, to learn from them how to provide a therapy service that met their needs and which they were able to engage with.
I have witnessed the ways in which women who lived through trauma in childhood are punished over and over again in adulthood for the adverse effects of that trauma, including how, for the most part, they are excluded from therapeutic services. One of the main barriers to care is that many are dual diagnosis, but are refused access to mental health care on the grounds that their psychosis is driven by their substance use. They are signposted to addiction services but are far too unwell to engage, and so they are left with no care, ending up dead or in prison. We live in a society where more value is placed on one life than on another.
Over the years of this work, which takes place in hostels and day centres for women in street prostitution, as well as for women who have escaped from traffickers, a distinct model of therapy has emerged. Rooted in Object Relations Theory, I called the model ‘therapy of presence’, referring to the importance of the presence of the therapist, maintaining the therapeutic alliance over periods when the client is absent at times when their life is too chaotic, or they are too unwell.
When I came to write up the model, looking back over 12 years of work with the women, a distinct pattern of engagement emerged:
The Four Stage’s of Street Talk’s therapy model
The first stage occurs when women have a crisis and see the therapist for about five weeks, until that crisis has passed. Although brief, this period of initial engagement lays the foundation for the therapeutic alliance that will develop at a later stage. The women seem to hold on to that experience, putting it to one side until needed.
During the second stage, which I refer to as ‘passive creative’, the women are mostly absent, caught up in the chaos and day to day survival of life on the street. This phase may last up to four years, with little formal contact between therapist and client. But women check in with the therapist from time to time, exchanging a word in passing, or sending messages through other women, as if making sure that the therapy door is still open. Looking back over this period at a later stage, women frequently say to the therapist, “You didn’t give up on me”. The continued presence of the therapist over this period seems to be what enables the therapy.
The third stage happens when women find their motivation to engage, usually following some significant, life-changing event. Women find their way back to the Street Talk therapist, even when they have been absent from the therapy for years. This sometimes involves women going to considerable effort to locate the therapist and get back in contact when they have been on the street, or moving from hostel to hostel, or in prison. At this stage, women engage with the utmost commitment to the therapy, attending regularly, usually weekly. This stage represents a period of discovery and release for the client, an untangling of suffering. Women sometimes say, “I know why I am here”. Usually for the first time, they create a narrative of their life where the causal link between childhood trauma and suffering in adulthood becomes apparent.
The fourth stage allows women to work from a more peaceful place, post so-called recovery, when they are free from violence, exploitation, prostitution and addiction. This period is one in which women can reconcile with themselves and do the most profound work, leading towards the end of their engagement with Street Talk.
The aim of Street Talk’s work has been to enable women to encounter their own humanity. In working with the women, I have encountered my own humanity, and am humbled every day of my working life by the courage of the women and the capacity of the human spirit to soar above suffering. I know how privileged I have been to do this work. I have learned that anybody, however vulnerable and however complex their needs, can engage in therapy, and that however hopeless a life looks, anyone can recover. It is never time to give up on someone. I originally wrote Street Talk: Not Angry But Hurting to ensure that Street Talk would continue to practice this model into the future, but I also hope it might encourage inclusion across other services.
Street Talk: Not Angry, But Hurting, by Pip Hockton, is published on March 31 by Free Association Books To learn more about this work visit Street Talk.
NB The term ‘prostitution’ (as opposed to ‘sex work’) is used deliberately in this blog to refer to the situation of women who do not have a choice.