When the threat
is ongoing.
How can I ‘process’ it when he’s still my carer?
Why trauma work that assumes the danger is over can fail disabled people, what research shows about risk, and why safety comes first.
What this is: a guide to trauma work when harm hasn’t stopped.
Why it matters: disabled people face higher risk of violence, sometimes from those who provide care.
The sharpest reframe: fear of a present threat isn’t a symptom of the past.
One thing to take away: attend to present danger early, and let the person decide what else happens alongside it.
Content note: this page discusses violence and abuse of disabled people, including by carers, without graphic detail.
The short version
Many trauma treatments assume the danger is in the past: that the task is to process what happened and to learn that the present is safe. For many disabled people, the threat isn’t over. Research shows disabled adults and children face higher rates of violence than non-disabled people, and some harm comes from the very people or services that provide care. When someone still depends on a person who hurts them, or a system that keeps putting them at risk, safety needs attention early: naming the threat, and supporting the person while services act to reduce it. That doesn’t always mean trauma treatment must wait. Practical protection and psychological help can sometimes proceed together, depending on the person’s goals and what the treatment would ask of them.
You might recognise this
Illustrative statementsDrawn together from common experiences. They are not quotes from individual people.
What research shows about risk
Research findingAdults
A 2012 meta-analysis (Hughes and colleagues) of 26 studies found that adults with disabilities had higher odds of experiencing violence than non-disabled adults: a pooled odds ratio of 1.50. The estimate for adults with intellectual impairments was similar (1.60). An odds ratio isn’t quite the same as “1.5 times the risk”, and results varied considerably between studies, populations and types of disability.
Limits: the review is now over a decade old; study quality varied; some types of disability and violence were little studied; and few studies came from low- and middle-income countries.
Children
A companion meta-analysis (Jones and colleagues, 2012) found that disabled children were around three to four times more likely than non-disabled children to experience several types of violence. Pooled estimates suggested that about 27% had experienced physical violence and 15% sexual violence.
Limits: all included studies were from Europe or the USA, and most focused on violence by parents.
Colette is 44 and has spinal muscular atrophy. She relies on agency personal assistants for almost everything. One PA has been rough with her, mocks her, and once left her in bed all morning. She complained; the agency said they would “look into it”. He is still on her rota twice a week. Her GP refers her for trauma therapy because she has nightmares and panics before his shifts.
Colette is a fictional teaching example, not a real person.
When the danger is ongoing
Our frameworkColette’s panic before those shifts isn’t a symptom of the past intruding into a safe present. It is an accurate response to a present threat. Treatment that asks her to revisit memories while the PA is still coming risks making her feel worse, and can imply the problem is her reaction.
Name the threat
Say clearly what is happening and that it isn’t acceptable.
Support action to reduce it
Safeguarding, a formal complaint, an advocate, documenting incidents with consent. Removing a harmful worker is the service’s responsibility; therapy supports the person’s decisions and shouldn’t become the route through which they have to earn protection.
Support the person meanwhile
Ways to get through, people to contact, plans for afterwards, and, if the person wants and it is feasible, psychological treatment alongside.
This isn’t a fixed sequence. The therapist weighs the present danger, the support available, the person’s goals and the demands of the proposed treatment. The site shouldn’t pressure anyone into memory work, or imply that everyone living with unresolved risk must wait indefinitely for help.
The same logic applies to less dramatic but chronic threats: repeated benefit reassessments, a hostile workplace, unreliable care that leaves someone unsafe. See Threat, Drive and Soothing.
A reminder, or something happening now?
Our frameworkFear in an appointment may come from a reminder of earlier harm, from something wrong now, or both. Avoid telling someone their body is reacting to the past when nobody has examined the present.
A reminder, in a setting that is respectful now
Possible focus: recognising the reminder and exploring its effects.
Harm or coercion happening now
Possible focus: protection, practical support and appropriate action.
Uncertain current risk
Possible focus: clarifying information and preparing for different possibilities.
Earlier learning intensifying a real present threat
Possible focus: practical preparation and therapeutic work, together.
When you depend on the person who harms you
Our frameworkStandard safety advice, such as leaving or cutting contact, may be impossible when someone provides essential care. Safety planning has to include who would provide care instead, how the person would get out of bed or eat tomorrow, and how to report harm without losing support. Therapists need to know local safeguarding routes and disability-aware domestic abuse services, and to respect the person’s pace and decisions unless there is a serious risk that requires action.
What it might sound like
Before we talk about the nightmares, can I ask about now? Is the PA still coming?
Tuesdays and Fridays.
Then I don’t think the first thing to work on is your memories. The first thing is that you aren’t safe on Tuesdays and Fridays. Would you want help with that?
Yes. But if I push too hard they might drop me altogether.
That’s a real risk, and you get to decide how we handle it. Could we look at what you’d want, and who could back you up, before anything goes to the agency?
What changes: with Colette’s agreement, the therapist helps her contact an independent advocate. The advocate supports a written complaint and a safeguarding referral; the agency is responsible for acting on it, and three weeks later the PA is removed from her rota. Meanwhile, Colette and the therapist work on her sleep and on getting through the remaining shifts. Her nightmares continue for some months. When she chooses, they begin trauma-focused work on what happened. Some nights are still bad.
What needs attention here?
Harm is still happening
Possible focus: safety, with the person’s consent
Watch for: processing the past while ignoring present danger
The person depends on whoever harms them
Possible focus: safety planning that includes replacement care
Watch for: advice to leave or cut contact
Fear is described as a symptom
Possible focus: whether it is an accurate response to present danger
Watch for: calling it hypervigilance
The person fears losing support if they report
Possible focus: their pace and choices, and advocacy
Watch for: acting without them, unless serious risk requires it
Possible starting points, agreed with the person, not rules.
How you’d know it helped
- The present threat is named and, where possible, reduced.
- The person feels believed.
- Psychological help, including trauma-focused work if wanted, is offered when it fits, not withheld until everything is resolved.
Words you can use
For clientsQuestions worth carrying, as a therapist
Therapist Reflection- Is the danger past, or still present?
- Am I treating an accurate fear as a symptom?
- Do I know the safeguarding and advocacy routes for disabled people locally?
Evidence & sources
Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it.
Hughes, K., Bellis, M. A., Jones, L., Wood, S., Bates, G., Eckley, L., McCoy, E., Mikton, C., Shakespeare, T. & Officer, A. (2012), “Prevalence and risk of violence against adults with disabilities: A systematic review and meta-analysis of observational studies”, The Lancet, 379(9826), 1621–1629. doi:10.1016/S0140-6736(11)61851-5
Jones, L., Bellis, M. A., Wood, S. et al. (2012), “Prevalence and risk of violence against children with disabilities: A systematic review and meta-analysis of observational studies”, The Lancet, 380, 899–907.
The sequence of naming, reducing and supporting, and the guidance on dependence, are this site’s synthesis.
Colette and the dialogue are constructed for learning. She is not a real person.
We have not located research on trauma therapy for disabled people while harm by a carer is ongoing.
Last reviewed: October 2026.
How to cite this page: Donaghey, C. (2026). When the Threat Is Ongoing. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/what-is-psychotherapy/trauma-informed-approaches/when-the-threat-is-ongoing/ (Accessed: [date]).
Shared under CC BY-NC 4.0, with an extra permission to teach from it on fee-paying courses. Credit the site. See Reusing This Material.