Healing Tasks

Psychotherapy with Adult Survivors of Childhood Abuse

James I. Kepner

• Publisher: Gestalt Press
• Year: 2013
• eBook ISBN: 9781135060763
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

This groundbreaking book presents a new model for working with survivors of abuse and other trauma. The Healing Tasks Model, based on developmental stages of healing with specific tasks for each stage, offers the clinician new support for threading through the sometimes overwhelming complexities of the survivor's experience. At the same time, Kepner's model helps to avoid some of the common pitfalls and risks of work in this most challenging of clinical areas, such as pushing clients to express and remember before they have developed the capacity to manage such intensity, or encouraging confrontation and interpersonal interactions that the survivor doesn't yet have the developmental underpinnings to support.

Using the Healing Tasks Model the clinician will find techniques for helping clients develop emotional and systemic supports, manage feelings, and set appropriate boundaries. Readers will also find a guide to dealing with the difficult and troubling issues of memory: how to approach abuse memories, when and how to take action based on abuse memories, when to defer action pending the development of more supports and capacities for the survivor, and then how to develop those essential supports and capacities.

Written for psychotherapists, psychologists, psychiatrists, social workers, counselors, pastoral counselors, and adult survivors of childhood abuse, Healing Tasks provides a therapeutic model that can be used to help abuse survivors develop the emotional skilles to lead richer and more fulfilling lives.

Chapter One
Healing Tasks for Survivors of Abuse

The Healing Tasks Model for survivors of abusive trauma is based on principles and concepts derived from Gestalt therapy. The model is oriented to the framing of the tasks for client and therapist. In the journey of healing from difficult life experiences, these tasks influence the choices made about the timing and the nature of therapeutic work. There are no easy answers and, in my experience, there is no magic that can make the healing process quicker or simpler. Even those who do "brief therapy" acknowledge that these issues are not amenable to quick solutions, that survivors often need an ongoing relational context for healing, and that treatment can be only "as brief as possible" (Dolan, 1991).

But there is some sense to the process of healing, and there are understandings that can help to prevent it from being more difficult and painful than it needs to be. The Healing Tasks Model is a guide to making sense of this process. Healing cannot be pain-free, but we certainly should aim to minimize, as much as possible, the traumatizing effects of the treatment itself.

Healing as Cure Versus Healing as Growth

I have focused on the tasks involved in the healing process because I believe that healing is fundamentally about growth. In our culture, we are biased in our understanding of what healing means because of the pervasive metaphor of scientific medicine: one goes through specific stages of healing from a "disease" toward an eventual static state, from wound to sepsis to control of infection to scarring; or from infection to mobilization of the immune system to control of infection to recovery. The medical model sees disease as a foreign condition against which one's body mobilizes to cope; with proper aid, the body will fight disease off in stepwise fashion, with a resulting end state of health if treatment is successful. This metaphor of healing has had great utility in the mastering of certain conditions. But with the advent of psychoneuroimmunology, even modern medicine is finding it to be limited in significant ways.

The model presented here looks at healing somewhat differently. Broadly speaking, the survivor of traumatic situations is not dealing so much with a "disease" as with compromises of the natural course of growth that were made in the service of survival and self-integrity. As a result of the abusive trauma and the coexisting problematic environment, the natural processes of attachment (Bowlby, 1969; Winnicott, 1960, 1988), learning, accomplishment, assimilation, and differentiation (Piaget, 1962) have been reshaped in relation to many critical developmental functions. Healing, then, is really the process of reestablishing the natural cycle of growth and development in relation to those developmental issues that have been most affected (distorted, truncated, redirected, rigidified, or fixated) by the abusive situation. Healing from the impact of childhood abuse and trauma is fundamentally a process of growth.

In healing as growth, as opposed to a linear progression toward cure, we address and readdress certain issues in ever more accomplished and more differentiated ways, in much the same way as we learn any complex task—speaking, reading, or writing, for example. We do not achieve one stage and move on to the next, leaving the previous stage behind. Rather, the healing process is more like the creation of an oil painting: the background is painted in, and then details are added, and then washes and tone are overlaid on the whole. But the painting is not yet done, for the background still has to be refined in light of the emerging details, and then more details will be added and shifted, and as these elements take on new weight and interactions, the tone and the cast of the canvas will be shifted and refined by the artist. Each part of the painting supports and refines the previous part and is supported and refined in turn.

To put this idea another way, growth proceeds in a spiral fashion. We visit and revisit complex issues and tasks with increasing mastery, breadth, and capacity. We approach previously intolerable risks at each new level of the spiral. At each round, at each pass, a new reorganization of the whole field, the whole gestalt, occurs as new capacities are integrated and assimilated, old traumas are undone, and a new self emerges in engagement with the world. The growth tasks that I see as most central to healing from such childhood trauma are described in the section that follows.

Developing Support

Support is the relational ground of the environment that provides the context for all growth and development. It is the essential framework of attachment and relationship to caring and responsive others, by whose actions we learn to affirm our own existence, basic trust, and to care for ourselves. Most survivors, by virtue of the distinct lack of support they received developmentally, and of their current need for support, given the overwhelming quality of their symptoms and their life experience, find this task crucial to the creation of an adequate systemic frame for life and growth.

In human development, support is the fundamental interpersonal base on which all other developments must rest. The infant or child is embedded in an interpersonal field of caretakers, family, and community (Stern, 1985; Winnicott, 1960, 1988; Bowlby, 1969). The disturbance of support that is so common—indeed, virtually definitional—in the abusive context means that survivors often remember abuse without useful or adequate support in the present because they adapted themselves to living without it in the past. And without support, little else can be usefully addressed.

Development of the Self Functions

Self functions embody the capacity to manage and integrate experience, interactions with the environment, and interactions with oneself. Self functions, the means by which we manage our experience and interactions, are learned in relation to the developmental context in which we are growing. If our developmental context provides a place where we can experiment, then our self functions will be flexible. If our developmental context responds to our feelings, then we will learn to have a differentiated variety of modulated feelings. If we can engage with the environment in a way that allows us to experience and test our interpersonal boundaries, and if the environment both supports our differentiation and places appropriate limits on our use of aggression toward others, then we will develop a clear sense of both self and other, of how to connect as well as separate.

Survivors typically have had only a few choices and have only a narrow range of skills for managing their experience. The abusive context skewed the development of self functions either in the direction of dealing with the overwhelming, the violating, and the uncaring or in the direction of compliance, withdrawal, and disconnection from bodily boundaries. A context that recognizes no ownership of personal boundaries skews the development of boundary functions. A context that floods a child with overwhelming feelings and sensations skews the development of feeling functions toward numbing, dissociation, lack of differentiation, or explosive expression. An environment that does not respond to or help modulate the intensity of stimulation does not support the development of the self functions by which the child could regulate and pace his or her own experience of stimulation.

Without adequate self functions, the abreaction of traumatic memories is itself often experienced as traumatic because nothing new is brought into the survivor's relationship to the archaic situation so as to make contact with it in the present experientially different from contact in the past. Here is the greatest flaw in the abreactive method of dealing with trauma.

Undoing, Redoing, and Mourning

Because the survivor was a child when the abuse occurred and had little power or capacity to maintain his or her boundaries with integrity, much of the abusive context has become internalized and is experienced as information about himself or herself, rather than about experience in relation to another. If we are not allowed or able to act on our own behalf—to run away, to push away, and to stop what is occurring—then we must turn such impulses, which are directed at the environment, in some other direction. Usually they are turned back on the self (retroflected), so that we become frozen, self-punishing, full of self-restraint and caution, and they are internalized (introjected, or swallowed whole), so that we become full of beliefs, statements about ourselves, and so on, which are actually foreign material and inappropriate to our needs. If the environment shames and humiliates us, then we may come to feel that we are shameful or worthless. If secrecy is demanded of us, then we may become self-contained, silent, and full of secrets that even we do not know.

What is essentially contextual—an engagement between the child and a particular environment—will be perceived as personal when it is removed from its context. By virtue of the limits placed on the child's ability to engage fruitfully with the environment, and because the child has to act on himself or herself in order to manage and adapt, the adaptations come to be experienced as if they had to do only with the child's side of the engagement. Instead of being able to respond to shaming by saying, "Stop making me feel bad," the child comes to feel that he or she is bad. If to avoid unpredictable punishment the child has to constrain his or her behavior so as not to be noticed, he or she develops tense muscles and a withdrawn posture.

Thus, in current behavior, "personality style," interpersonal relations, and current symptoms, we see much that is actually reenactment of the abusive context, much that is actually internalization of or adaptation to the traumatic context, much that is actually derived from the environment or learned in relation to it. Undoing involves restoring the proper relationship of organism to environment through expressive work, therapeutic reenactment, and dialogue, as well as through real-life actions. Such intense work is appropriately done only when adequate support and self functions exist for the survivor, to allow dealing with this task in a way that is not itself traumatic. And, as the realities of the survivor's history are fully confronted, the survivor must also mourn and come to terms with the losses suffered through abuse: the loss of childhood, the struggle just to live, the loss of an idealized image of the parent, and so on.

Reconsolidation

Learning comes in many forms, and all learning results in growth of some kind. A lot of learning appears to be incremental; we steadily build our pool of understanding, knowledge, skills, and capacities. Other learning requires more than adding a new layer of bricks to an existing structure. This learning restructures the existing edifice and completely reorganizes it—broadening, encompassing, and integrating all its parts into a new whole, a new gestalt. This process is akin to the paradigm shift described by Kuhn (1970) and to the process of accommodation described by Piaget (1962). The reorganization is not just of one's "internal" process; it is a reorganization of one's perceptions, one's behavior toward others and the way one makes meaning of oneself and the world. Thus, it is a reorganization of the whole field, by which we mean the person or organism and the environment.¹Our sense of self is not formed in isolation; it includes our whole environment, our whole being (known and unknown), and our life context—past, present, and future.

I use the term reconsolidation to refer to this reorganization of the field because it is a repetitive process by which we solidify and reorganize our experience. It results in growth. Reconsolidation is the perceptual and experiential reorganization of the current field so that it can become larger, more complex in its organization, and more differentiated as a whole. It then allows for richer and more satisfying meaning and living.

For the survivor, reconsolidation initially may involve a reconstituting of his definition of life and of his person to include previously unremembered abuse as part of the past and as part of the definition of himself (his "I"). Continuing in the course of growth and development, he must find an increasingly inclusive, more differentiated and complex context of meaning in place of the traumatic experiences in his life. The survivor does not simply add new memories; the new memories often force him to redefine who he knows himself to be. The survivor does not merely learn new skills and capacities; he becomes a different person. The survivor does not simply change himself; his relationships, family life, and interactions with others are also changed.

Healing Tasks and the Phases of Healing

Healing from abuse—or healing in general, for that matter—seems not to be a linear process. We can stretch ourselves only so far in one direction before we discover that we must attend to our support. We find ourselves having to go back over what seems to be old ground, reworking and redoing at a more integral and refined level, before we can move ahead into uncharted territory. Our cultural belief in the linearity of progress blinds us to the recursive nature of most human ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• The Author
• Chapter One: Healing Tasks for Survivors of Abuse
• Chapter Two: Developing Support
• Chapter Three: Developing Self Functions
• Chapter Four: Undoing, Redoing, and Mourning
• Chapter Five: Reconsolidation
• Chapter Six: Assessing the Healing Process
• Chapter Seven: Memories and Remembering
• Chapter Eight: Enactment and Recontextualization
• Chapter Nine: The Body Process in Healing
• Epilogue
• Notes
• References
• Assessment Instrument
• Index