Not Trauma Alone

Therapy for Child Abuse Survivors in Family and Social Context

Steven Gold

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9781583910276
• eBook ISBN:
  9781134942411
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

How is an individual to lead a comfortable, productive existence when he or she was never taught the skills necessary for effective living? Adult survivors of child abuse often face this dilemma. Instead of being nurtured as children and taught life-skills by their caregivers, child abuse survivors were subjected to a daily regimen of coercive control, contempt, rejection and emotional unresponsiveness. It is not surprising, therefore, that many survivors encounter difficulty adjusting from this type of damaging childhood atmosphere to one in which they have autonomy. This book addresses the particular problems associated with treating adult survivors of child abuse. Until now, psychotherapy for child abuse survivors often centered on the trauma of their abuse experiences. However, survivors frequently reveal a history suggesting it was not abuse trauma alone that created their difficulties, but growing up essentially alone - without the consistent emotional support and guidance needed for development of effective functioning. This book presents an alternative to trauma-focused treatment that, though effective for treatment of other forms of trauma, can induce deteriorated rather than improved functioning in survivors of prolonged childhood maltreatment. The contextual therapy presented in Not Trauma Alone delineates a psychotherapeutic approach that emphasizes helping survivors develop the capacities for effective functioning that were never transmitted to them during their formative years. Detailed descriptions of the methods and interventions comprising contextual therapy are included in this critical book for all mental health professionals, clinicians, academics, and students in the field.

Part I
Abuse in Context: The Conceptual Framework

From a historical perspective, widespread recognition among mental health professionals of the prevalence of child abuse and its long term adverse impact on psychological functioning is a relatively recent development. Contemporary awareness of abuse and its effects has, from its inception, been intimately related to the concepts of trauma and posttraumatic stress disorder. This section traces the emergence of these constructs, considers some of their limitations, and proposes, based on empirical and clinical evidence, an alternative conceptualization of the sources and nature of the difficulties in adult adjustment that are commonly experienced by survivors of childhood abuse. It presents the argument that survivors of prolonged child maltreatment often grow up in family environments that fail to teach them many of the fundamental daily-living skills required for effective adult functioning, and that this, as much as the discrete incidents of abuse to which they have been subjected, is the source of many of their difficulties.

1
Chapter
Abuse: The Trauma Model

Abuse. Trauma. Not very long ago, these were not words that were encountered with any regularity. In a remarkably short span of years, they have become part of everyday speech. In the process, these two words have come to be so closely associated with each other that they are sometimes used interchangeably. What happened during that relatively brief period of time to transform our thinking about issues that, until then, had remained invisible to so many of us?

Around 1980, several social and academic trends converged to catalyze a recognition of the prevalence of child abuse and of its potentially devastating effects on adult functioning. Over the subsequent twenty years, growing awareness of maltreatment of children has had a profound influence not only on theory, research, and practice in psychology, but on society as a whole. Before the 1970s the topic of child abuse was almost entirely absent from psychological literature (Kempe & Kempe, 1978; van der Kolk, Weisaeth, & van der Hart, 1996). In contrast, there are now several professional journals devoted entirely to child maltreatment. Countless articles on the topic appear in journals devoted to a more general readership, and numerous books have been published on the subject. In the popular media, coverage of some aspect of child abuse is regularly encountered on television talk shows, in newspapers and news programs, in magazines, and in feature films.

□ The Social Context of the Recognition of Abuse Trauma

One of the major developments that stirred awareness of child abuse was the rise of the women's movement in the 1970s. Feminist socio-political analysis was instrumental in directing attention to the frequency with which women and children were subjected to victimization and violence. In the 1970s and early 1980s, groundbreaking works by authors who were strongly influenced by feminist scholarship on the nature and damaging effects of rape (Burgess & Holstrom, 1974), woman battering (Walker, 1979), and child sexual abuse (Herman, 1981) emerged, following each other in rapid succession. These investigators set in motion a decisive shift in society's awareness of violence perpetrated against women and children. In a way that is difficult for those whose formative years came after 1980 to appreciate, acts of violence that once seemed rare are now recognized as commonplace, and their consequences, which once were minimized, now generate a degree of compassion and responsiveness more consistent with their severity and destructiveness.

Another primary contributor to recognition of the pernicious consequences of child abuse was much less obviously and directly related to child maltreatment—the aftermath of the Vietnam War. The traumatic effects of combat experience had been repeatedly documented in the professional literature throughout the succession of armed conflicts in this century. With the passing of each war, gains in understanding and treating combat-related syndromes had slipped into oblivion (Herman, 1992a; van der Kolk et al., 1996). In the years following the Vietnam War, however, the situation differed from that of earlier post-war periods in several respects. For one thing, various conditions distinguished the war in Vietnam from earlier wars. One of the most significant among these conditions was that a tour of duty in Vietnam was restricted to one year (Bourne, 1978). For this and other reasons, psychiatric casualties in Vietnam were appreciably lower than they had been in previous wars. It gradually became apparent, however, that the psychological consequences of combat exposure among many Vietnam veterans only began to emerge after their tour of duty ended. This delayed reaction was probably largely due to the isolation experienced by many Vietnam veterans. As opposed to the hero's welcome afforded homecoming soldiers from World War I and World War II, soldiers coming back from Vietnam were often ignored or derided for their service due to the unpopularity of the war. Further contributing to their segregation were the individualized schedules created by the twelve month tour of duty system, organized so that each soldier returned separately, usually unaccompanied by comrades (Bourne, 1978).

The unpopularity of the war, the extensive experience of "stress disorders" among Vietnam veterans, and discontent with what they perceived as a lack of responsiveness to their combat-related distress moved veterans to remain vocal about the psychological toll combat had taken on them. Rather than allowing themselves to be silenced by stigmatization, they lobbied to have their post-combat difficulties taken seriously (Figley, 1978a; Herman, 1992a). As a result, combat-related stress disorders came to be acknowledged as a legitimate field of study in the professional literature (Figley, 1978a).

In a manner with little precedent, these two movements represented the refusal of disempowered groups, women in the former case and combat veterans in the latter, to allow the psychological damage inflicted on them by social injustice go unheeded and without reparation. Instead of accepting the prevailing social view that such impairment was a sign of weakness, they insisted that their difficulties be acknowledged as an expectable reaction to horrific experiences. Their efforts contributed to the formation of a unique psychiatric diagnostic category, posttraumatic stress disorder (PTSD; Figley, 1978b; Haley, 1978). This diagnosis was distinctive in that it included among its criteria the explicit statement that etiology was attributable to circumstances extraneous to the person being diagnosed, that is, a traumatic event: "a recognizable stressor that would evoke significant symptoms of distress in almost everyone" (American Psychiatric Association, 1980, p. 238). The implication of this criterion was that PTSD did not primarily reflect that there was something defective about the person being diagnosed, but rather that there was something inherently destructive about the situation to which she or he had been exposed.

The codification of the diagnostic syndrome of PTSD and its adoption in 1980 into the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, American Psychiatric Association, 1980) was largely guided by the work of investigators of responses to combat experiences in Vietnam (Figley, 1978b; Haley, 1978; van der Kolk et al„ 1996). It was not long, however, before extensive commonalities were noted between the reactions observed among Vietnam veterans and those catalogued by investigators studying rape, child physical abuse, woman battering, and child sexual molestation (Herman, 1992a; van der Kolk et al„ 1996). The symptoms of PTSD are often grouped into three major categories: (a) intrusive reexperiencing—images, thoughts, sensations, and dreams that spontaneously impinge upon awareness, usually in response to cues that serve as reminders of the trauma; (b) numbing and avoidance—attempts to circumvent situations reminiscent of the trauma along with emotional and sensory "shutting down"; and (c) arousal—a generalized state of agitation marked by characteristics such as hypervigilence, heightened startle response, and irritability. All three classes of symptoms were included in the diagnostic criteria for PTSD in the DSM III-R (1987), and were retained in the DSM-IV (1994). The presence of the first two of these three symptoms groupings was highlighted in the writings of Mardi Horowitz (1969, 1970; Horowitz & Solomon, 1978). Horowitz emphasized that this pattern of intrusion and numbing manifests regardless of the particular type of traumatic event experienced. The symptoms of reexperiencing and shutting down, therefore, were as characteristic of abused women and children as of combat veterans. The conclusion seemed obvious. Whether it occurred on the battlefield, in the streets, or in the privacy of domestic settings, exposure to violence seemed to have essentially identical psychological repercussions.

□ Abuse, Trauma, and Memory

From early on, therefore, the study of child abuse and its long term effects has been closely linked with the concept of trauma and the syndrome of PTSD. It has seemed axiomatic, since child abuse was recognized as a form of trauma, that treatment approaches for adult survivors of child abuse should approximate those for survivors of other forms of trauma. This perception was bolstered by the "rediscovery" of Freud's (1959/1893, 1959/1896; Breuer & Freud, 1955/1895) early works on the role of trauma in the etiology of psychopathology. Even before the inception of the diagnosis of PTSD, this initial period of Freud's psychological theorizing had been referred to by some as his "trauma model" (e.g., Loevinger, 1976; Miller, 1984). In the 1980s and early 1990s, a variety of authors writing about child sexual abuse in particular (e.g., Bass & Davis, 1988;Blume, 1990; Briere & Conte, 1993; Courtois, 1988; Herman, 1981; Herman & Schatzow, 1987) and trauma in general (e.g., Herman, 1992a; Waites, 1993) revisited Freud's trauma model. They noted that almost a century earlier, Freud (1959/1896) had attributed many neurotic symptoms, especially hysterical ones, to the traumatic effects of child sexual abuse. He also pointed out similarities between hysterical neurosis and what was then referred to as "traumatic neurosis"—neurotic symptoms that manifested in response to physical injury, that is, trauma (Freud, 1959/1893). In all likelihood, Masson's 1984 book, The Assault on Truth: Freud's Suppression of the Seduction Theory, which predated the other works by only a few years and was cited in most of them, helped to fuel this trend. Masson alleged that Freud had abandoned his trauma theory, or, as it was labeled by Freud himself, "seduction theory," not on the basis of evidence, but because it was met with incredulity and disdain. Masson's thesis, reflected in the title of his book, was that Freud's "personal failure of courage" (p. 189) led him to abandon and obscure the truth in response to a hostile sociopolitical climate.

It is true that seduction theory was based on the contention that hysterical symptoms had their origins in childhood sexual abuse. In Freud's (1959/1896) own words:

Sexual experiences in childhood consisting of stimulation of the genitals, coitus-like activities, etc. are therefore in the final analysis to be recognized as the traumata from which proceed hysterical reactions against experiences at puberty and hysterical symptoms themselves

(p. 202).

However, Freud (1959/1896) insisted that a history of childhood sexual abuse itself was not a sufficient cause of hysteria. Integral to his seduction theory were the processes of loss and subsequent recovery of recollections of abuse trauma.

We have heard and acknowledged that there are many people who have a very clear recollection of infantile sexual experiences and yet do not suffer from hysteria. This objection really has no weight at all, but it provides an occasion for a valuable comment. People of this type should not (according to our understanding of neurosis) be hysterical at all, at least not in consequence of scenes which they consciously remember. In our patients these memories are never conscious; we cure their hysteria, however, by converting their unconscious memories of infantile scenes into conscious recollection (p. 207). . . . From this you perceive that it is not merely a question of the existence of the infantile sexual experiences, but that a certain psychological condition enters into the case. These scenes must exist as unconscious memories; only so long and in so far as they are unconscious can they produce and maintain hysterical symptoms.

(p. 208)

With the revival of Freud's trauma model, therefore, came general acceptance not only of the concept that psychological symptomatology in adults could be traced to sexual abuse in childhood, but also of the notion that it was not simply the abuse experience, but the obliteration of memories of abuse from conscious awareness, that was the key etiological factor. The result was that some therapists, following the lead of Freud's trauma model, assumed that the lifting of amnesic barriers through encouraging retrieval of abuse memories was critical to recovery from the effects of child sexual abuse. This conviction was bolstered by research investigations providing evidence that loss and subsequent recovery of abuse memories occurs among at least a substantial minority, and possibly the majority, of adult survivors of childhood sexual abuse (Briere & Conte, 1993; Herman & Schatzow, 1987; Loftus, Polonsky, & Fullilove, 1994; Williams, 1994). Empirical evidence supporting the existence of the phenomenon of loss and subsequent recovery of traumatic memories continues to accumulate. In a review of 25 studies of traumatic memory, Scheflin and Brown (1996) concluded that the preponderance of the data supports the existence of amnesia for childhood sexual abuse and the accuracy of recovered abuse memories.

Despite these findings, the notion of amnesia with later retrieval of abuse memories has generated tremendous controversy. Those disputing the existence and validity of this phenomenon (e.g., Loftus, 1993; Ofshe & Watters, 1994; Wakefield & Underwager, 1992; Yapko, 1994) argue that what are alleged to be recovered recollections of abuse are actually false memories, implanted by therapists. They contend that clinicians subscribing to the belief that amnesia for abuse is common among survivors of childhood molestation unwittingly employ suggestive and leading questioning in a manner that encourages the elicitation of responses consistent with their expectations.

Existing data are inconsistent with the claim that in the majority of instances, recovered memories are false recollections implanted by therapists. In a general population study by Elliott and Briere (1995), participants with a childhood sexual abuse history reporting recovered memory were no more likely to be in therapy than those reporting continuous memory. In what was apparently a different set of analyses of the same general population sample (Elliott, 1997), participants ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Series Foreword
• Foreword
• Preface
• Acknowledgments
• PART I ABUSE IN CONTEXT: THE CONCEPTUAL FRAMEWORK
• PART II TREATMENT IN CONTEXT: FOUNDATIONS OF THE THERAPEUTIC MODEL
• PART III ACQUIRING TOOLS FOR DAILY LIVING: THE STRUCTURE OF THE THERAPEUTIC PROCESS
• PART IV CONCLUSION