Transforming the Legacy

Couple Therapy with Survivors of Childhood Trauma

Kathryn Karusaitis Basham, Dennis Miehls

• Publisher: Columbia University Press
• Year: 2004
• eBook ISBN: 9780231509237
• Topic: Social Sciences
• Subtopic: Marriage & Family Sociology
• Index: Social Sciences

To serve the increasing numbers of individuals who have survived interpersonal and domestic violence, or as refugees, have sought asylum from political violence, armed conflict, or torture, Transforming the Legacy presents an innovative relationship-based and culturally informed couple therapy practice model that is grounded in a synthesis of psychological and social theories. This unique couple therapy model encompasses three phases of clinical practice: Phase I entails a process of establishing safety, stabilization, and a context for changing legacies of emotional, sexual, and/or physical abuse. Phase II guides reflection on the trauma narrative. The goal of phase III is to consolidate new perspectives, attitudes, and behaviors.

Within these phases, the model—illustrated with rich case studies—focuses on specific issues, including: intersubjectivity between the client and clinician (such as transference and countertransference, vicarious traumatization, and racial identity development); intrapersonal, interactional, and institutional factors; the role of the "victim-victimizer-bystander" dynamic in the couple and therapeutic relationships; preserving a locus of control with clients; flexibility in decisionmaking regarding clinical processes; and specific practice themes, such as the composition of a couple, the role of violence, parenting, sexuality, affairs, dual diagnoses, and dissociation.

A dramatic departure from formulaic therapeutic approaches, this biopsychosocial model emphasizes the crafting of specific treatment plans and specific clinical interventions to show how couple therapy can transform the legacies of childhood traumatic events for a wide range of populations, including military couples and families, gay lesbian/bisexual/transgendered couples and families, and immigrant and refugee couples and families. This thorough attention to issues of cultural diversity distinguish Transforming the Legacy from the current literature and make it an invaluable resource for clinicians in a wide range of professional disciplines.

COUPLE THERAPY PRACTICE

This section contains four chapters that are devoted to the explication of the phase-oriented couple therapy approach. This practice model is grounded in a synthesis of social, family, trauma, object relations, and attachment theories, which have been reviewed separately in Section II (Theoretical Foundations). Throughout this third section, our effort is to demonstrate the coherence of this case-specific model, drawing from different theoretical perspectives that are useful at a particular phase of the work or in response to a specific presenting issue.

In Chapter 8, we focus on the biopsychosocial assessment. Because any assessment functions as an integral part of treatment, we initially provide a clear contextual frame by summarizing the salient features of the practice model. Then, we review the relevant institutional, interactional, and intrapersonal factors that contribute to a thorough biopsychosocial assessment.

In Chapter 9, we describe how the biopsychosocial assessment guides the creation of a treatment plan. Then, we discuss ways to build a facilitative therapeutic alliance, setting the stage for a detailed review of the therapy phases (i.e., Phase I: Safety, stabilization, and establishment of a context for change; Phase II: Reflection on the trauma narrative; and Phase III: Consolidation of new perspectives, attitudes, and behavior). Finally, we address specific practice themes that are central with all traumatized couples in therapy. They include: (1) the composition of a “couple,” (2) the role of violence, (3) parenting, (4) sexuality, (5) affairs, (6) dual diagnoses (i.e., substance abuse/addictions and complex posttraumatic stress disorder), and (7) dissociation.

Chapter 10 focuses on the clinician’s responses in working with traumatized couples in a couple therapy frame. We explore the influences of vicarious traumatization, racial-identity development, countertransference phenomena, and the realm of intersubjectivity.

Finally, in Chapter 11, we feature a case example, the couple therapy with Rod and Yolanda, which illuminates the use of a phase-oriented couple therapy practice model. Our attention now turns to the crafting of a complete biopsychosocial assessment.

Biopsychosocial Assessment

In this chapter we review the relevant institutional, interactional, and individual factors that constitute a thorough biopsychosocial assessment. As we introduce the metaphoric image of couple therapy as a challenging journey, a biopsychosocial assessment should serve as both a compass that directs the course of the work and an anchor that stabilizes the focus. Undoubtedly, the assessment emerges as a central feature of any couple therapy venture that ultimately determines the direction and guides the movement of the work. However, before we embark on a detailed analysis of the assessment procedure, we will situate this process in the context of the phase-oriented couple therapy practice model, which is summarized in the next section. (A more detailed account of the treatment model is presented in Chapter 9.)

:: OVERVIEW OF PHASE-ORIENTED COUPLE THERAPY MODEL

The synthesis of theoretical models used in practice depends on the unique features and needs assessed for each couple. For example, as social constructionist, racial identity, and feminist theories serve to clarify the family’s social context, these perspectives broaden the assessment (Marsella, Friedman, Gerrity, & Scurfield, 1996; Pouissant & Alexander, 2000).

Intergenerational and narrative family theories inform our understanding of intergenerational family assumptions, rituals, and unique multiple meanings (Sheinberg & Fraenkel, 2001; Trepper & Barret, 1989; White, 1995; White & Epston, 1990). Finally, in the individual arena, trauma theories focus on the short- and long-term neurophysiological effects of trauma on brain function, particularly memory and affect regulation (Krystal et al., 1996; Shapiro & Applegate, 2000; van der Kolk, 1996). To strengthen further an understanding of each partner’s inner world, psychodynamic theories, more specifically object relations and attachment theories, shed light on the interplay of the inner and outer worlds (Kudler, Blank, & Krupnick, 2000; Pearlman & Saakvitne, 1995; Scharff & Scharff, 1987). They also provide an internal conceptual scaffolding for this practice model in all cases through understanding relational patterns and guiding reparative therapeutic experiences. Finally, a review of the cognitive and behavioral functioning of each partner also addresses mastery, coping, and adaptation (Compton & Follette, 1998). In summary, this synthesis of biological, social, and psychological theory models informs the biopsychosocial assessment that subsequently guides the direction of practice. The relational (i.e., object relations and attachment theory) and social theory models provide anchoring throughout the entire course of couple therapy. Other theoretical models advance to the foreground or recede into the background depending on the presenting issue at hand.

In spite of the creative variability that enters into each couple case assessment, some general guidelines are useful for all assessments and decision-making regarding the sequencing and choice of interventions. Overall, this couple therapy practice approach functions as a phase model that parallels many contemporary individual and group psychotherapy stage models with trauma survivors (Courtois, 1988; Herman, 1992; Miller, 1994). However, there are distinct commonalties and differences between these models. In general, stages are similar to phases in terms of identifying certain uniform challenges, yet traditional stage models presume essentialist sequential development. During the past ten years, greater emphasis has been placed on phase-oriented individual and group psychotherapy models (Chu, 1992, 1998; Courtois, 1999; Figley, 1988; Gelinas, 1995; Pearlman & Saakvitne, 1995). Our phase-oriented couple therapy model approximates these models more closely, anticipating that relevant themes may be revisited flexibly at different periods throughout the work. The phases of couple therapy include Phase I: Safety, stabilization, and establishment of a context for change; Phase II: Reflection on the trauma narrative; and Phase III: Consolidation of new perspectives, attitudes, and behaviors (see Table 8.1). This fluid process calls forth an image of a three-dimensional triple helix with continuously interconnecting themes that weave together in an animated tapestry.

TABLE 8.1 :: Phase-Oriented Couple Therapy: Phases

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Phase I: Safety, Stabilization, and Establishment of Context for Change

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1. Assessment of safety

2. Self-care

• Physical health

• Mental health (e.g., depression, anxiety, and unresolved grief)

• Sleep, nutrition, and exercise

• Substance use and abuse

• Biobehavioral strategies for stress reduction and self-soothing

3. Relevant diversity themes

4. Support systems (e.g., religion/spirituality, family, and community)

5. Communication skills

6. Assessment of partnership status (i.e., continuation? stasis? dissolution?)

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Phase II: Reflection on Trauma Narratives

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1. Exploration of meaning of traumatic experiences

2. Intergenerational legacy of victim–victimizer–bystander pattern

3. Exploration of different meanings of intimacy

4. Creation of healing rituals

5. Clarification of projective identification processes (Only in cases in which each partner possesses the object relational capacities, sufficient ego strengths, and the ability to bear ambivalence will this intervention be indicated.)

6. Emergence of memories (Only in cases in which each partner possesses the object relational capacities and ego strengths to bear the retrieval of traumatic memories might the uncovering of memories be indicated. Congruence with cultural beliefs must exist as well.)

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Phase III: Consolidation of New Perspectives, Attitudes, and Behaviors

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1. Remediation of presenting issues

2. Increased empathy for resiliency and survivorship in partners’ listening to each other’s trauma narratives

3. Shifts in victim–victimizer–bystander dynamic leading toward equitable relating

4. Enhanced sexual relationship

5. Strengthened capacities for self-differentiation, object constancy, and self-care

6. Self-definition that moves beyond survivorship identity

7. Changes in parenting style

8. Strengthened social identities (e.g., gender, race/ethnicity, sexual orientation, age, disability, religion, class, etc.)

9. Shift in social consciousness

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Phase I: Safety, Stabilization, and Establishment of Context for Change

Phase I tasks are relevant for most, if not all traumatized couples in therapy. Here, it is essential to determine if the couple has secured basic safety in terms of food, shelter, and freedom from domestic or external violence. As mentioned earlier, an advocacy role is assumed to ensure safety for a victim if physical violence is detected. A couple therapy modality is contraindicated at such times as it often inflames an incendiary dynamic.

Assessment of self-care is strengthened by psychoeducational support about posttraumatic stress disorder (PTSD) and complex PTSD symptomatology. The clinician explores how well each partner cares for his or her basic physical and mental health needs. After reviewing the safety of the external environment along with efficacy of self-care, the clinician needs to assess the extent of interpersonal supports among family, friends, and colleagues.

In general, this phase involves a full range of psychoeducational, cognitive–behavioral, body–mind, spiritual, and ego-supportive interventions that promote adaptation and coping. Collaboration with relevant support systems such as school, treatment professionals, Department of Social Services (DSS), and probation officers is often crucial during this phase as well. Many couples are content to end their therapeutic work after completing these Phase I tasks, if the major presenting issues have been resolved. Such cognitive–behavioral changes can positively influence a couple over a sustained period and can readily be accomplished within a brief time frame. Many couples may choose to move along to Phase II or III work, which involves a reflection on and restorying of the trauma narrative. However, not all couples need to follow such a course of therapy in order to establish new and more equitable ways of relating.

Phase II: Reflection on the Trauma Narratives

Phase II involves sharing original perspectives on the childhood trauma experiences while restorying the narratives with a new focus on resiliency and adaptation. Since there has been so much controversy about the utility of uncovering traumatic memories, many couples benefit, instead, from a reflective sharing of their traumatic experiences without full affective reexperiencing. Instead, an integration of affect, cognition, and memory emerges as a distinct therapy goal. In addition, increased capacity for empathic attunement often occurs during this sharing of experiences.

Congruence with sociocultural influences may also determine the usefulness of uncovering of traumatic memories. If such a path promotes flooding or decompensation, uncovering work is clearly contraindicated. In addition, when there are distinct cultural prohibitions against catharsis, such affective reexperiencing is also contraindicated. For example, I worked with a couple who fled as political refugees from a Central American country; both partners had suffered torture and imprisonment from caregivers and prison guards during their respective childhoods. Cultural, religious, and political forces joined together to create a shared worldview that valued containment, while devaluing expressiveness of intense affect. In this case, a cognitive reflection of the aftereffects of trauma and the “victim–victimizer–bystander” dynamic helped this couple. Retrieval of memories was clearly contraindicated.

Finally, object relational and attachment capacities also determine the efficacy of uncovering traumatic memories. If partners have not yet attained object constancy and lack the capacity to sustain ambivalence in intimate relationships, then, once again, uncovering of traumatic memories would be contraindicated.

An important point to revisit is that we, as clinical social workers, continue to overvalue the importance of the uncovering of traumatic memories under the guise of privileging an insight-oriented psychotherapy frame. Even when cultural congruence and object relational capacities exist, it remains preferable to focus on safety and stabilization work if the couple reports satisfaction with their Phase I progress. If continued work is indicated, Phase II tasks would then focus on reflecting on, and through this process, restorying the trauma narrative. With cultural congruence and object relational capacities intact, these couples may then benefit from clarification of their projective identification processes.

Phase III: Consolidation of New Perspectives, Attitudes, and Behaviors

Phase III tasks involve a focus on family of origin work along with further strengthening of family and community relationships. Couples at this point often report less shame, stigma, and isolation. They often move beyond self-definitions as “survivors” to “overcomers,” “transcenders,” or “thrivers.” To shift from a self-definition exclusively as survivor, the partner(s) explore their feelings associated with the experience of victim or bystander, which occurs fairly easily, as well as the aggressive feelings associated with their victimizing parts, which is more difficult. When each partner develops the capacity to own each of the “victim–victimizer–bystander” roles, he or she is better able to sublimate aggression into more proactive and creative activities. This transition often involves an abandoning of a rigid self-definition, which is linked exclusively to the traumatic experiences. During this phase, parenting can become less problematic, and couples may express a greater sense of mastery, vitality, and joy. Couples may also engage themselves in political and social action as a way to advocate for safer childhoods. Resolution of the tasks undertaken during these phases of couple therapy does not follow a sequential developmental line. Instead, a more realistic path involves a revisiting of different phases throughout the course of the work.

An example is the case of a dual-trauma couple, discussed in the chapter on military couples, which consists of Johnnie, a forty-two-year-old Vietnam veteran helicopter pilot, and Jeannie, a forty-one-year-old thrice-married beautician. Both partners wrestled with the sequelae of childhood physical and sexual abuses and chronic, repetitive trauma in their adult lives. After five months of couple therapy focused primarily on physical safety, self-care, remediation of psychiatric symptomatology, relapse prevention, and strengthening of support networks, both partners were ready to discuss repair work with their respective families of origin, using their understanding of the “victim–victimizer–bystander” dynamics (Phase II and Phase III work). Although some progress was noteworthy, Johnnie failed to attend his twelve-step meetings, and Jeannie regressed to self-mutilative cutting. When these symptomatic behaviors surfaced, the harm reduction and stabilization measures embedded in Phase I work were revisited until criteria were met sufficiently once again to address interpersonal issues. In contrast to following a steady, sequential path in therapy, a couple more typically vacillates back and forth between the assessment phase and Phases I, II, and III of the couple therapy model.

:: GUIDELINES FOR BIOPSYCHOSOCIAL ASSESSMENT

A central reciprocal question arises: In what ways do the aftereffects of trauma influence individual capacities for a partnership, and in what ways do these aftereffects influence the relationship itself? Since each couple is unique and complex, it is necessary to engage a couple in a thorough biopsychosocial assessment that guides careful decision-making regarding sequencing and choices of practice interventions. Each clinician is urged to identify both strengths as well as possible vulnerabilities in each of the sections of the assessment outline (i.e., the institutional, interactional, and individual) (see Table 8.2). Inevitably, various questions arise that explore the strengths and vulnerabilities within each partner and within the couple relationship.

TABLE 8.2 :: Phase-Oriented Couple Therapy: Biopsychosocial Assessment Factors

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I. INSTITUTIONAL (grounded in social constructionist, feminist, and racial identity development theories)

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1. Clinician attitudes and responses (racial identity, vicarious traumatization, countertransference)

2. Extended family and community support

3. Service delivery context (social policies, finances, political contexts)

4. Previous and current mental health treatment

5. Diversity (race, ethnicity, religion, socioeconomic status, disability, sexual orientation, gender)

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II. INTERACTIONAL (grounded in intergenerational and narrative family theories)

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1. Victim–victimizer–bystander dynamic

2. Power and control struggles

3. Distancing and distrust

4. Boundaries

5. Sexuality and physical touch

6. Communication

7. Dearth of rituals

8. Meaning of trauma narrative

9. Intergenerational patterns

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III. INTRAPERSONAL

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A. Individual, cognitive, affective, and behavioral functioning (grounded in trauma theories)

1. Areas of resilience

2. Complex PTSD symptomatology

F ears (nightmares, flashbacks, intrusive thoughts)

E go fragmentation (dissociation, identity distortion)

A ffective changes/addictions and compulsive behaviors/antisocial behavior

R eenactment

S uicidality/somatization (insomnia, hypervigilance, numbness vs. hyperarousal, startle response, bodily complaints)

B. Intrapsychic (grounded in object relations and attachment theories)

1. Capacity for whole-, part-, or merged-object relations (Mahler/Horner)

2. Themes of symbiosis, differentiation, practicing, rapprochement, and “on the road to object constancy” (Mahler/Horner)

3. Internalized victim...

Table of contents

• Cover 
• Half title
• Title
• Copyright
• Dedication
• Contents 
• List of Figures and Tables
• Preface
• Acknowledgments
• Section I :: Context
• Section II :: Theoretical Foundations
• Section III :: Couple Therapy Practice
• Section IV :: Specific Clinical Issues
• References
• Index