The Social Work and Sexual Trauma Casebook

Phenomenological Perspectives

Miriam Jaffe, Jerry Floersch, Jeffrey Longhofer, Megan Conti, Miriam Jaffe, Jerry Floersch, Jeffrey Longhofer, Megan Conti

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9781351751001
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This volume offers a collection of ten case studies from clinical social workers who work in the field of sexual trauma, with the objective of challenging and informing social work practice with survivors and perpetrators of sexual trauma. These steps are meant to help the process of treatment by breaking down the experience of trauma to a set of steps and interventions aimed at resolving traumatic symptoms within a given time frame. Our text seeks to challenge the tendency towards reductionism inherent in the dominant social paradigm by encouraging the development of a phenomenological and interdisciplinary approach to understanding sexual trauma. In doing so, the examples of interventions presented in each case study reflect practice methods that honor the complexity of the human experience of sexual trauma, suffering, and recovery.

1
Thinking Critically about Sexual Trauma in the 21st Century

Megan Conti

Pre-reading Questions

1. When you think of sexual trauma, what images or ideas emerge? Who are the victims? What are the circumstances?
2. What do you think might be different about how we conceptualize sexual trauma in the 21st century as opposed to the 20th century?
3. In what ways might structural elements and systems of power influence our understanding of sexual trauma?

Over the past 25 years, literature on defining and treating trauma has increased significantly. This development has been part of an open discussion in the media and in public forums about trauma and its various manifestations (Watters, 2010; Fassin & Rechtman, 2009; Kirmayer, Lemelson, & Barad, 2007). Most notably, the increase in trauma theory and research can be linked to a post-Vietnam War social consciousness and the increase in feminist theory about domestic violence and child abuse (Herman, 1992b; McNally, 2004). Such knowledge has undergone an identifiable spike since the early 1990s, as marked by the publication of Judith Herman’s first edition of Trauma and Recovery and the emergence of Bessel van der Kolk’s research on neuroscience and its relationship to trauma. This spike has resulted in what can now be identified as the “social phenomenon” of trauma, in which trauma has become an identified social problem that requires attention and, more often than not, empathy (Fassin & Rechtman, 2009). This increase has occurred amid the emergence of managed health care, in which mental health is increasingly reliant on diagnostics and psychopathology for the provision of care (Rosenberg, 2007; Kirschner, 2013). In tandem, diagnostic language and concepts have become part of contemporary discourse and identity development (Marecek & Gavey, 2013). With these developments come important considerations regarding the epistemological significance and social influence of trauma and its partner, complex trauma (Young, 1995).

Research has demonstrated that trauma responses can be considered on a spectrum (Kaminer & Eagle, 2017), and this spectrum includes proposed subsets of trauma, most notably Complex Post-traumatic Stress Disorder (PTSD; Herman, 1992a). Complex PTSD, with its recognition of the differing symptomatic, characterological, and relational presentations of victims of repetitive exposure to trauma, was a response to the limitations of a traditional trauma diagnosis of PTSD (Herman, 1992a; Newman, Riggs, & Roth, 1997; Pelcovitz et al., 1997; Cloitre et al., 2009; Sar, 2011; Hyland et al., 2017). Traumatic experiences captured by the frame of Complex PTSD include repetitive interpersonal violence perpetrated by close caregivers or important attachment figures (Herman, 1992b; Ford & Courtois, 2009), as well as other types of trauma that involve larger, structural and transnational forces (Hardy, Compton, & McPhatter, 2013).

Through the evolution of our understanding of trauma, treatment research has developed an approach to human suffering that has become an embodiment in and of itself, and has perpetuated key assumptions about the recovery process (Lester, 2013). In general, mainstream trauma treatment theories tend to follow a trajectory of steps that facilitate the healing process (Herman, 1992b; Foa & Rothbaum, 1998; Resick & Schnicke, 1992; Ehlers & Clark, 2000; Shapiro, 1995; Schauer, Neuner, & Elbert, 2005; Dorrepaal et al., 2014; DeJongh et al., 2016). Therapists are encouraged to develop a feeling of safety with their patients, at which point the patient is then guided on a journey during which they open up about their trauma, generating a narrative that leads them to an ultimate truth about their suffering (Herman, 1992b; Schauer, Neuner, & Elbert, 2005). Ultimately, the process is meant to empower patients and help them to reconnect with their world in a new way (Herman, 1992b). Other theorists rely heavily on brain imaging, citing that our advances in neuroscience will help us to pinpoint the changes in the brain that take place after a traumatic experience and, in doing so, will guide our way through the process of recovery (Van der Kolk, 2014; Elsey & Kindt, 2017; Zaleski, Johnson, & Klein, 2016; Rau & Fanselow, 2007; Bremner, 2007). The shift to neurobiology in the study of trauma mimics the larger shift in psychology toward reliance on neuroscience and carries with it significant implications for treatment (Kirschner, 2013). While these developments in our understanding of trauma and trauma theory are valuable and integral to our understanding of the etiology of and symptoms characterizing trauma, what is the extent of their influence on our approach to treating victims of significant trauma?

When considered from a perspective that is experience-near to a patient’s narrative, questions regarding diagnostic relevance and treatment framing emerge. Rather than being, as Lester (2013), “carved out of the flow of everyday existence and… bracketed as a ‘thing’ that is discernible against the backdrop of a person’s life” (p. 755), a patient’s presentation can be messy and complicated. Furthermore, the patients’ understanding of themselves can be subversive of our application of diagnostic and positivistic practice wisdom with its a priori approach to treatment (Guilfoyle, 2013), or the biological reductionism of the medical model (Kirschner, 2013). An individual’s experience of trauma does not take place in a vacuum from which we can extract a trauma narrative and a healing trajectory. Instead, the experience of trauma is couched in a person’s life experiences and informed by her understanding of herself and her world. As such, it becomes unique and distinctly harder to capture, and treatment recommendations should reflect this nuance.

When approached from a frame that is tied closely to a patient’s experience of himself, and pushing back against the dominant, medicalized, scientific understanding of mental illness, clinicians are free to explore individual accounts of suffering from a phenomenological approach that honors the individual’s right to understand and define the components of their experience and their meaning (Hornstein, 2013). A larger, phenomenological focus becomes particularly relevant when individuals who have suffered from what might be diagnosed as Complex PTSD present for treatment having developed an identity completely divorced from that of their victimhood. These are individuals whose experience of trauma is embodied on a daily basis due to structural and environmental influences or who have incorporated a trauma narrative into their identity in ways that are culturally informed and do not necessarily involve ideas such as truth or recovery. For such people, Burstow (2003) argues, psychiatric diagnoses “cannot do justice to the psychological misery of people’s lives, never mind the social conditions that give rise to the misery” (p. 1300). These patients remind clinicians and researchers that experiences of trauma defy reductionism. In so doing, these patients caution us against an overreliance on positivist definitions of traumatic nosology, regardless of their presenting symptomatology.

In order to approach trauma from a perspective that honors a patient’s relationship to his traumatic experiences (which is necessarily ontologically and epistemologically different than the dominant treatment paradigm), we must consider how each patient’s experiences and his interactions with the world add up to his narrative and his understanding of himself and his trauma. In doing so, we are allowing for the true complexities of the human experience to illuminate for us the inherently layered nature of exploring trauma and trauma treatment. While concepts like Complex PTSD help us to better understand experiences of extreme and prolonged exposure to trauma, they do not necessarily translate to a helpful frame for all patients whose presentation meets the criteria for this diagnosis/formulation. When patients do not identify with their trauma, or do not identify their trauma as such, we are challenged to consider how to approach treatment from a lens that is both trauma-informed and respectful of our patients’ development of the self.

Literature Review

The American Psychological Association’s Diagnostic and Statistical Manual (DSM; 2013) and its categorization of mental illnesses serve an important purpose. The DSM has helped guide clinicians as well as individuals suffering from mental illness through the process of making sense of what can be frightening, uncomfortable, and life-threatening experiences (Hornstein, 2013). Specifically, Complex PTSD research has provided a helpful expansion of diagnostic criteria and framing for understanding cases where the nature of the traumatic experience is repetitive and prolonged, and where the patient’s presentation tends to fall outside of the parameters established by a traditional PTSD diagnosis (Herman, 1992a; Newman, Riggs, & Roth, 1997; Pelcovitz et al., 1997; Cloitre et al., 2009; Sar, 2011; Ford & Courtois, 2014; Ford, 2015; Hyland et al., 2017). Complex PTSD refers to trauma that is developmental in nature, meaning that traumatic experiences are repetitive and additive, typically occurring over a period of time, and taking place in relational contexts that are influential to the victim’s development (Sar, 2011; Gleiser, Ford, & Fosha, 2008; Courtois, 2004). The central contribution of Complex PTSD to the psychiatric nosology is the added attention to “disturbances predominantly in affective and interpersonal self-regulatory capacities” (Cloitre et al., 2009, pp. 399–400). In expanding the clinical focus to involve understanding a patient’s mood and relational issues, Complex PTSD helps to guide the clinician to better understand how complicated traumatic experiences have the potential to have a pervasive effect on a victim’s development and ongoing life experiences.

However, the authority, influence, and power with which the DSM operates (as well as concepts, like Complex PTSD, that emerge from DSM diagnostic categories) is problematic (Georgaca, 2013; Hornstein, 2013; Kirschner, 2013; Burstow, 2003; Marecek & Gavey, 2013; Cermele, Daniels, & Anderson, 2001). Feminist, poststructuralist, and antiracist theorists have noted that the dominant influence of psychiatry and the ongoing expansion of diagnoses and criteria have resulted in the “colonization” of mental health practices (Cosgrove & Wheeler, 2013). This colonization involves an increase in the number of people who qualify for diagnoses, a neurobiological reductionism that conflates symptoms with a biological origin that is largely unfounded, and the oversimplification of complicated human experiences (Cosgrove & Wheeler, 2013; Hornstein, 2013; Fee, 2000; Kirmayer, Lemelson, & Barad, 2007). Additionally, poststructuralists argue, the shift toward greater medicalization of mental illness reflects more of what is constructed as mental illness and knowledge than an objective truth upon which all practitioners can agree (Cermele, Daniels, & Anderson, 2001). As such, approaching mental illness from a psychiatrically informed position is fraught with clinical (and potentially ethical) concerns related to what constitutes truth and knowledge, whose experience is honored, whose agenda is served, and whose treatment is considered when creating labels and frames for human experience.

A limitation to randomized, controlled studies of treatment effectiveness is the way in which controlled environments fail to capture the real life circumstances of trauma treatment, particularly in community-based mental health facilities (Kaminer & Eagle, 2017). Despite its “scientific” validity, an understanding of trauma and trauma treatment that grows out of a psychiatric appreciation of human suffering is inherently limited in its scope (Burstow, 2003). Current diagnostic paradigms tend to focus on the interpersonal experience of trauma and fail to consider the larger, structural powers that contribute significantly to an individual’s daily traumatization and polyvictimization (Quiros & Berger, 2013). In reality, diagnostic categories upon which research and evidence-based practice models are founded do not reflect the reality of daily trauma experienced by vulnerable members of society (Ali, 2004; Bryant-Davis & Ocampo, 2005). The impact of systemic racism, sexism, heterosexism, ableism, and cisnormativity are daily and powerful, resulting in systems of oppression and trauma that traditional approaches to trauma fail to capture.

Additionally, diagnoses emerge from a cultural embodiment that privileges the white, male, heterosexual, cisgender, dominant narrative and this narrative was used to conceptualize a PTSD diagnosis (Burstow, 2003; Georgaca, 2013). The culturally defined nature of diagnostic categories in general, and trauma and trauma diagnosis in particular, has been well documented (Young, 1995; Bur-stow, 2003; Kirmayer, Lemelson, & Barad, 2007; Watters, 2010; Fassin & Rechtman, 2009; Quiros & Berger, 2015; Georgaca, 2013). The American Psychiatric Association’s approach to mental illness emerges from American social structures, privileging the dominant class—white, male, middle class, able-bodied, heterosexual, and cisgendered (Burstow, 2003; Brown, 1995; Cermele, Daniels, & Anderson, 2001; Quiros & Berger, 2015). The construction of mental illness that emerges from such a frame fails to recognize “how race, class, age, gender, and other forms of bias undergird many of the diagnoses,” and fails to consider the nuance of individual experience (Cosgrove & Wheeler, 2013, p. 94). In addition, feminist scholars have noted, such models tend to pathologize gendered racial/ethnic responses to stressors in the interest of privileging power structures as normal (Cermele, Daniels, & Anderson, 2001; Brown & Ballou, 1992). Although the DSM is not intended to be a social commentary, it serves the function of reifying systems of power and significantly influencing how mental health practitioners and patients alike frame mental illness and human suffering (Guilfoyle, 2013).

Foucault’s (1988) identification of the individual’s resistance to being essentialized is particularly relevant when considering patients who present to treatment with identities that do not fit modern conceptualizations of mental illness or trauma (cited by Guilfoyle, 2013). Working with patients whose understanding of themselves and their life experiences embody this type of resistance to essentialism requires closer attention to their process of meaning making and the culturally informed embodiment of their experience. As such, there are instances when one’s approach to complex trauma requires a discerning frame that honors feminist, postmodern, and intersectional conceptualizations of illness and treatment approaches. Although the evidence for treating PTSD supports approaching treatment with trauma-focused cognitive behavioral therapy (TF-CBT; Cusack et al., 2016; Schnyder et al., 2015), prolonged exposure (Foa & Rothbaum, 1998), or eye movement desensitization and reprocessing (EMDR; Shapiro, 1995), a relational, phenomenological approach to treatment is indicated. Such treatment allows for a patient’s own process of meaning making and self-exploration to emerge free from the confines of the DSM or other diagnostic categories. In doing so, our use of case material as the point of analysis enables us to consider the ways in which nuanced clinical narratives can illuminate practice questions centered on the development of the self, honoring a patient’s meaning making, and privileging a patient’s narrative development.

Case Vignette: Ava

Ava made a strong first impression. Stunningly beautiful, she had a radiant and welcoming smile bracketed by deep dimples in her caramel-colored skin. Ava also had these dark, almond-shaped eyes that gave her a haunting look, communicating her emotional depth and underlying pain. When Ava appeared in my office for the first time for her intake appointment, she was visibly nervous and unsure, but somehow conveyed a deep commitment to the potential for this process to work. As we began to talk about her life and her experiences, I was impressed by how mature and articulate she was; she was wise beyond her 17 years. As the details of her life became intimately known to me over time, however, I began to understand why. Ava had suffered significant sexual trauma at the hands of her uncle. Additionally, ...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• List of Contributors
• Introduction: Using Case Studies of Sexual Trauma in the Classroom
• 1 Thinking Critically About Sexual Trauma in the 21st Century
• 2 Virtual Trauma: Social Work With Adolescents in the Online Era
• 3 Victim or Offender?: Stigma and Justice in a Complex Forensic Case
• 4 Sexual Abuse, the Therapeutic Alliance, and Therapist Self-Disclosure
• 5 Redefining Resilience in Children: A Story of Strength and Survival
• 6 Social Work and Sex Trafficking: Therapeutic Intervention in the Commercial Sexual Exploitation of Children
• 7 Social Work With an Adolescent Female Sex Offender
• 8 In-Home Treatment for In-Home Sexual Trauma: The Case of Becky
• 9 The Silent War Within: Military Sexual Trauma
• 10 Social Work, Sex Addiction, and Psychodynamic Treatment
• Index