Rebuilding Shattered Lives
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Rebuilding Shattered Lives

Treating Complex PTSD and Dissociative Disorders

James A. Chu

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eBook - ePub

Rebuilding Shattered Lives

Treating Complex PTSD and Dissociative Disorders

James A. Chu

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About This Book

Praise for Rebuilding Shattered Lives, Second Edition

"In this new edition of Rebuilding Shattered Lives, Dr. Chu distills the wisdom he has gained from many years spent building and directing an extraordinary therapeutic community in a major teaching hospital. Both beginners and experienced clinicians will benefit from this book's unfailing clarity, balance, and pragmatism. An invaluable resource."—Judith L. Herman, MD, Director of Training for the Victims of Violence Program, Cambridge Health Alliance, Cambridge, MA

"The need for this work is immense, as is the reward. Thank you, Dr. Chu, for continuing to share your sustaining insight and wisdom in this updated edition."— Christine A. Courtois, founder and principal, Christine A. Courtois PhD & Associates, PLC, Washington, DC; author of Healing the Incest Wound: Adult Survivors in Therapy and Recollections of Sexual Abuse

Praise for the first edition:

"Dr. James Chu charts a deliberate and thoughtful approach to the treatment of severely traumatized patients. Written in a straightforward style and richly illustrated with clinical vignettes, Rebuilding Shattered Lives is filled with practical advice on therapeutic technique and clinical management. This is a reassuring book that moves beyond the confusion and controversies to address the critical underlying issues and integrate traditional psychotherapy with more recent understanding of the effects of trauma and pathological dissociation." —Frank W. Putnam, MD

A fully revised, proven approach to the assessment andtreatment of post-traumatic and dissociative disorders—reflecting treatment advances since 1998

Rebuilding Shattered Lives presents valuable insights into the rebuilding of adult psyches shattered in childhood, drawing on the author's extensive research and clinical experience specializing in treating survivors of severe abuse.

The new edition includes:

  • Developments in the treatment of complex PTSD

  • More on neurobiology, crisis management, and psychopharmacology for trauma-related disorders

  • Examination of early attachment relationships and their impact on overall development

  • The impact of disorganized attachment on a child's vulnerability to various forms of victimization

  • An update on the management of special issues

This is an essential guide for every therapist working with clients who have suffered severe trauma.

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Information

Publisher
Wiley
Year
2011
ISBN
9781118015063
Edition
2
Part I
The Nature and Effects of Childhood Abuse
1
Trauma and Dissociation
30 Years of Study and Lessons Learned Along the Way1
Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. When the force is that of nature, we speak of disasters. When the force is that of other human beings, we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning.
 Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life.
 They confront human beings with the extremities of helplessness and terror, and evoke the responses of catastrophe.
— Judith Lewis Herman, MD, Trauma and Recovery (1992b, p. 33)
Our current understanding of trauma and dissociation is relatively recent, beginning to emerge only about 30 years ago. Posttraumatic stress disorder and the dissociative disorders—as we currently understand them—were first codified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980. Given what we now know about the effects of severe and chronic trauma, it is extraordinary that so little about it was acknowledged or understood just a few decades ago. What contributed to this pervasive blindness to critical issues that affect the many traumatized persons in North American society? The answer to this question is complex and has historical precedents.
Since the late 19th century the pendulum has swung between recognition and denial of the abuse of children, particularly sexual abuse. Pierre Janet (1907) wrote extensively about the relationship between trauma (including childhood abuse) and dissociation. In his 1896 publication, The Aetiology of Hysteria, Sigmund Freud (1896) postulated a link between childhood sexual abuse and psychiatric illness, a theory that he subsequently disavowed (Simon, 1992). Clearly, the Victorian values of Freud’s time may have contributed to his disavowal of his “seduction hypothesis,” which implied that incest was commonly the underlying cause of a wide variety of symptoms that were ascribed to female “hysteria,” including fainting, nervousness, insomnia, weakness, muscle spasms, shortness of breath, irritability, loss of appetite, and diminished libido. However, the result of Freud’s disavowal was the subsequent denial of the reality of abuse by generations of psychiatrists, psychologists, and other mental health professionals. The noted psychoanalysts Elizabeth Zetzel and William Meissner (1973) captured this stance beautifully in one of their texts on psychoanalytic theory and practice:
The abandonment of the seduction hypothesis and the realization that the patient’s reports of infantile seduction were not based on real memories but fantasies marked the beginning of psychoanalysis as such. The importance of reality as a determining factor in the patient’s behavior faded into the background.
 The focus of analytic interest turned to the mechanisms by which fantasies were created. (pp. 72–73)
Thus was the foundation laid for professionals to dismiss the realities of their patients’ reports for generations. As recently as the 1980s, respected psychiatrists might have interpreted a patient’s report of early sexual molestation by her father as “fantasies derived from Oedipal wishes” (meaning that the patient as a child had fantasized the incest because of her wish for a kind of sexual involvement with the parent of the opposite sex). This view implied that adult women were often unable to distinguish between fantasy and reality, and essentially blamed the patient for her own victimization. At that time, psychodynamic psychiatry was still dominated by classic psychoanalytic thinking, where conflicts about sexual drives, instincts, and fantasies were considered more important than the possible reality of occurrence of actual abuse. In fact, even when professionals believed that sexual abuse had occurred, the major emphasis was the resulting intrapsychic conflicts and not on the actual experience and aftereffects of the molestation.
Even among enlightened and sensitive professionals, the harsh facts concerning abuse are easily forgotten. For example, in spring 1992, a national organization released the results of a large-scale study, Rape in America: A Report to the Nation (National Victim Center, 1992). The grim statistics reported that one in eight women in this country were likely to be the victims of forcible rape during their lifetimes. Even more striking was the finding that nearly 30% of rape victims were less than 11 years old, and that more than 60% of rape victims were under the age of 17. These statistics actually underestimated the prevalence of rape, because although each victim was counted only once, some victims reported having been raped on multiple occasions (as is often the case in incestuous abuse). The results of the study were widely covered in the national press and on network and cable television news. Somewhat surprisingly, in the subsequent weeks, fewer and fewer professionals had any recollection of the essential results of this study—including clinicians who were interested in issues of childhood abuse. Only three months later, I informally polled an audience of more than 200 attendees at a national conference on sexual abuse and found that not one person recalled hearing about the study or the results. While this might be partially ascribed to the process of normal forgetting (in which even important events are progressively unavailable to conscious memory), the all-too-human need to deny these findings is likely to have played a major role in the lack of recall.
When it comes to interpersonal trauma, psychiatrist Judith Lewis Herman, MD (1992b), has pointed to a universal desire to look the other way—a natural human desire not to have to share the burden of the immense human suffering that derives from trauma and to accept some responsibility to ameliorate it. The societal denial of pandemic childhood trauma can perhaps be best understood through Herman’s theory that disturbing ideas, such as the etiologic link between child abuse and common adult psychiatric difficulties, can only be sustained in the context of societal support. It is indeed challenging for any society to have the maturity to be able to acknowledge that it has permitted some of its most vulnerable members to be severely abused and as a result to become profoundly impaired. The cultural implications of recognizing the extent of child abuse have strongly influenced the way that the field of trauma and dissociation is viewed and whether its findings can be acknowledged and accepted or denied and reviled. Herman has argued that any single individual does not have the ability to challenge entrenched cultural beliefs and norms, and that the support of a political movement is necessary to allow it to be truly seen and studied. The modern recognition and study of complex posttraumatic and dissociative disorders stemmed from two major political and sociologic phenomena: the Vietnam War and the Women’s Movement.
Historically, wars have forced societal attention to focus on the widespread and profound impact of overwhelming violence and trauma in postwar eras. In the United States, after the Civil War, a syndrome labeled “soldier’s heart” was described (Da Costa, 1871), which included rapid heartbeat and overall autonomic activation with startle responses and hypervigilance. Following World War I, many American and European soldiers were described as suffering from “shell shock,” a condition described as “emotional shock, either acute in men with a neuropathic predisposition, or developing as a result of prolonged strain and terrifying experience” or “nervous and mental exhaustion, the result of prolonged strain and hardship” (Southborough, 1922, p. 92). During and following World War II, clear posttraumatic syndromes were defined. Kardiner (1941) described a “physioneurosis” that included flashbacks, amnesia, irritability, nightmares, and other sleep disturbances. Saul (1945) used the term “combat fatigue” that resulted from overwhelming stress combined with the inability to act, and was manifested by emotional distress along with irritability, nightmares, and increase in heartbeat, respirations, and blood pressure. The original Diagnostic and Statistical Manual of Mental Disorders (DSM) was published by the American Psychiatric Association (APA) in 1952 during the Korean War, and the second edition (DSM-II) was published in 1968 during the Vietnam War. Both volumes recognized behavioral and emotional reactions to overwhelming fear or stress.
In the wake of the Vietnam War, an interesting paradox occurred. The war had become extremely unpopular, and by the fall of Saigon in 1975, most Americans were either politically opposed to the conflict or at least relieved to see an end to it. Most clearly did not want reminders of the failed war, and unlike more recent attitudes toward the military, many civilians regarded veterans as somehow tainted by their association with the recent conflict. Public opinion was so negative that veterans were reluctant to talk about their experiences or wear their uniforms in public. However, even in this climate of disavowal, health care professionals and eventually the American public had to acknowledge that a large cohort of young men and women returned from the war profoundly changed and damaged. This phenomenon facilitated the subsequent adoption of PTSD in the DSM-III in 1980. The increasing public and professional acknowledgement of the aftereffects of trauma allowed Vietnam veterans to be treated with a level of compassion and sophistication not seen in other postwar eras.
In 1983, Congress mandated the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990). Although the survey found that the majority of combat veterans made a successful adjustment to peacetime life, the NVVRS found that a substantial minority of Vietnam theater veterans continued to suffer from a variety of psychological and life-adjustment problems. Approximately 30% had experienced some form of posttraumatic problems. Even more alarming was the finding that for many veterans (approximately 12%), their PTSD had become a chronic condition. In a more recent study of 1,377 American Legionnaires 14 years after the NVVRS, 11% continued to suffer with more psychological and social problems, including marital problems with higher divorce rates, parenting difficulties, general unhappiness and difficulties functioning, and more physical problems, including pain, fatigue, and infections (Koenen, Stellman, Sommer, & Stellman, 2008).
Just as the Vietnam War focused attention on the effects of combat-related trauma, the Women’s Movement and the rise of modern feminism profoundly changed attitudes concerning trauma toward women and the welfare of children. The Women’s Movement provided the political will and social support to draw attention to long-neglected issues such as domestic violence, rape, and child abuse. Not surprisingly, many of the pioneers in the burgeoning trauma field in the 1970s and 1980s were women, many of whom embraced feminist values. Ann Wolbert Burgess, RN, DNSc, co-founded a crisis intervention program for rape victims at Boston City Hospital in 1972 (see Burgess & Holmstrom, 1974) and subsequently went on to become a pioneer in the study of the sexual assault on children and their exploitation in child pornography (Burgess, Groth, Holmstrom, & Sgroi, 1978). Similarly, Christine Courtois, PhD, co-founded a campus rape crisis center at the University of Maryland in 1972 and discovered that some clients of the center reported past sexual assault, including long histories of incest. Courtois went on to study and treat the effects of childhood abuse, helping other clinicians who were struggling to find guidance and support when there was a profound dearth of information on the subject of abuse and publishing the first major text on treating victims of incest, Healing the Incest Wound (1988). Our current understanding is that early sexual abuse can have devastating posttraumatic effects, but Courtois noted, “the most accurate diagnosis for incest response was posttraumatic stress disorder, an idea that seemed heretical at the time (1981) because PTSD was highly associated in the minds of clinicians with the Vietnam veterans” (p. xv).
In the 1970s, Herman began hearing many stories concerning incest in her adult women patients who had been diagnosed with borderline personality disorder. Despite the skepticism of the psychiatric establishment, she found the incest stories convincing and began a career of studying and treating sexual violence in our society. The result was the stunning book, Father-Daughter Incest (Herman, 1981), a scientifically credible work that documented the nature and undeniable harmful effects of sexual violation, which she saw as much more common than had been previously believed. Herman was one of the feminist pioneers who first understood the logical link between the trauma and betrayal of incest and the profound difficulties in functioning experienced by patients with borderline personality disorder.
CHILDHOOD ABUSE: THE HIDDEN EPIDEMIC
The pioneers of the study of childhood abuse and its effects did much to fuel subsequent investigation of the effects of trauma, including understanding the development of posttraumatic and dissociative symptoms and disorders. Little was known in the 1970s and early 1980s about the prevalence or effects of childhood sexual abuse. Earlier estimates of prevalence had reported a very low incidence of incest (e.g., Weinberg’s 1955 estimate of an average yearly rate of incest of 1.9 cases per million children). Similarly, no real data existed concerning the effects of child sexual abuse. Kinsey and his colleagues downplayed any negative effects of incest: “It is difficult to understand why a child, except for its cultural conditioning, should be disturbed at having its genitalia touched” (Kinsey, Pomeroy, & Martin, 1948, p. 121). In fact, one of Kinsey’s co-authors, Walter Pomeroy, was later infamously quoted as saying, “Incest between adults and younger children can 
 be a satisfying and enriching experience.
” (Pomeroy, 1976, p. 10). Interestingly, Kinsey and his colleagues were surprised by their finding of a high rate of attempted sexual contact in childhood from their interviews with adult women. They found that 24% of the women recalled sexual advances by adult males when they were children, but the researchers downplayed the importance of this finding because most approaches did not result in actual sexual acts (Kinsey, Pomeroy, Martin, & Gebhard, 1953).
Modern research on the prevalence of childhood sexual abuse has yielded disturbingly congruent information concerning the rates of abuse. In 1986, psychologist Diana Russell, PhD, published The Secret Trauma: Incest in the Lives of Girls and Women, which reported the results of a landmark survey of the prevalence of sexual abuse in women in the general population. In interviews of 930 women in the San Francisco Bay area, more than one-third reported some kind of unwanted sexual contact in childhood. About half of the reported sexual abuse was incestuous abuse—sexual abuse perpetrated by a family member. These findings were considered surprisingly high when they were first reported but have stood up well in subsequent studies of general population samples in North America (Briere & Elliott, 2003; Vogeltanz et al., 1999). Russell’s work and subsequent studies have made it clear that the sexual abuse of girls is widespread and that it occurs among all ethnic groups and throughout all socioeconomic levels of our society.
Studies of the prevalence of the sexual abuse of boys have shown lower rates as compared to girls, but the rates are still high; when using a broad definition of sexual abuse (e.g., unwanted sexual contact in childhood), studies have found that one in six or seven adult men in the general population report some kind of childhood sexual abuse (Briere & Elliott, 2003; Elliott & Briere, 1995; Finkelhor, Hotaling, Lewis, & Smith, 1990).
Much of the research concerning the rates of childhood abuse has focused on sexual abuse, not only because of the extreme violation of boundaries and roles, but also because it is easier to quantify and study. There are far fewer ambiguities in defining sexual abuse as compared to physical abuse, emotional abuse, and neglect. However, the focus on this one type of childhood maltreatment does not imply that the potential aftereffects for other types of abuse are less serious. The few prevalence studies of physical abuse in childhood have suggested rates of 20% to 30% for both girls and boys (Briere & Elliott, 2003; MacMillan et al., 1997). These studies, combined with other research, lead to the unfortunate conclusion that both childhood physical and sexual abuse is widespread in our society and internationally (Finkelhor, 1994) and is perpetrated on both girls and boys. Although both physical and sexual abuse occurs among all children, girls are more likely than boys to be sexually abused, and, as shown in at least one study, boys were more likely than girls to be physically abused (MacMillan et al., 1997).
BEHIND CLOSED DOORS: SHAME AND SECRECY
In addition to societal denial and disavowal, there are other powerful reasons why the abuse of children is frequently hidden. The nature of child maltreatment—particularly child sexual abuse—and the circumstances in which it occurs also lead to the tendency not to acknowledge its occurrence or its aftereffects. Almost invariably, children feel shamed and responsible for their own victimization. In two remarkable papers, psychoanalyst Leonard Shengold, MD (“Child Abuse and Deprivation: Soul Murder”; 1979), and psychiatrist Roland Summit, MD (“The Child Sexual Abuse Accommodation Syndrome”; 1983), elucidated the way those who are injured by childhood abuse come to blame themselves for having been victimized:
If the very parent who abuses and is experienced as bad must be turned to for relief of the distress that the parent has caused, then the child must, out of desperate need, register the parent—delusionally2—as good. Only the mental image of a good parent can help the child de...

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