The Child Survivor

Healing Developmental Trauma and Dissociation

Joyanna L. Silberg

• Editorial: Routledge
• Año: 2021
• ISBN:
  9781351049603
• Edición: 2
• Categoría: Psychology
• Categoría: Psychotherapy

In this second edition of Joyanna Silberg's classic The Child Survivor, practitioners who treat dissociative children will find practical tools that are backed up by recent advances in clinical research.

Chapters are filled with examples of clinical dilemmas that can challenge even the most expert child trauma clinicians, and Silberg shows how to handle these dilemmas with creativity, attunement, and sensitivity to the adaptive nature of even the most complex dissociative symptoms. The new edition addresses the impact of the Covid-19 pandemic on children and provides tips for working with traumatized children in telehealth. A new chapter on organized abuse explains how children victimized by even the most sadistic crimes can respond well to therapy.

Clinicians on the front lines of treatment will come away from the book with an arsenal of therapeutic techniques that they can put into practice right away, limiting the need for restrictive hospitalizations or out-of-home placements for their young clients.

Chapter 1
Trauma and Its Effects

“It’s like you’re on autopilot and someone else is controlling the switches,” stated Shawn Hornbeck, kidnap victim and sexual abuse survivor. With these words, he explained the dissociation, helplessness and terror that kept him tied to his kidnapper for over four years until his rescue by the FBI in 2007 outside of St. Louis—only 50 miles from his home (Dodd, 2009). When interviewed later about his trauma, Shawn stated, “Most people would say their greatest fear is probably dying, but that’s not mine. I would have to say my greatest fear is probably not being understood” (Keen, 2008).

At age 11, Shawn was abducted from his neighborhood and forced to live with a sex offender, who enrolled him in school, gave him a pseudonym, and enforced his enslavement with threats and rewards for compliance. Shawn felt his healing from the trauma of his abuse and captivity was directly tied to people understanding the helplessness and terror that kept him trapped with his abuser, enduring repeated trauma and humiliation.

Like Shawn Hornbeck, the children in this book have felt the helplessness and terror of their plight, felt like they have been on “auto-pilot” and that their behaviors are misunderstood even by well-meaning people. However, unlike Shawn’s trauma, their stories have captured no headlines. They have endured their trauma in isolation, but yearn to be understood with the hope that healing can follow from this understanding.

Trauma has been defined as events that are outside of the individual’s normal expected life experiences and are perceived as a threat to “life, bodily integrity” or “sanity” (Pearlman & Saakvitne, 1995, p. 60). The individual faced with trauma feels at that moment, or multiple moments in time, that they will not be able to survive. This experience of intense powerlessness is a hallmark of trauma. Martha Stout (2001) explained, “These events open up a corridor of essential helplessness and the possibility of death” (p. 53).

These feelings of being overwhelmed and pushed beyond the limits of one’s capacity to cope can be mitigated when the experience is shared with others. Traumatic experiences endured in isolation and secrecy, which is often the case for the traumatic experiences of the children and teens you will meet in this book, are some of the hardest experiences to overcome. Protecting the secret, as well as enduring the multiple effects of these experiences, causes children’s internal resources to become overtaxed, leaving fewer resources for the difficult work of healing.

As research about the effects of childhood trauma has proliferated, the field has made an important distinction between the traumatic results of single incident events (Type I) and long-term chronic trauma (Type II) whose onset is during early development (Terr, 1994). Herman (1992) used the term “complex trauma” to refer to early onset, relational trauma that leaves enduring effects on the traumatized person’s basic capacities. Herman identified six key areas of functioning that are impacted by early trauma, including alterations in affect regulation, consciousness, self-perception, view of the perpetrator, relationships, and systems of meaning. Later researchers and clinicians describing both adults and children have continued to refer to long-term early chronic relational trauma as complex trauma.

One source of information we have about the prevalence of trauma comes from the Adverse Childhood Events (ACE) study. Felitti et al. (1998) studied thousands of patients through the Kaiser Permanente Health system and determined that 60% of the adult population had experienced at least one “Adverse Traumatic Event,” including neglect, physical abuse, emotional abuse, sexual abuse, observing violence, or having parents with histories of mental illness or drug abuse. Most importantly, the number of the traumatic events experienced correlated with a variety of negative health outcomes showing that exposure to trauma has long-term and serious implications for individual health.

SOCIETAL DENIAL

The prevalence of multiple forms of trauma in the life of children has been confirmed by the ongoing data collected from the National Child Traumatic Stress Network database. The over 14,000 children referred for services through this national network endured an average of 4.7 different types of trauma—including physical abuse, sexual abuse, emotional abuse, neglect, exposure to domestic violence, illnesses, losses or exposure to natural disaster, violent assaults, or community violence (Kisiel et al., 2011).

Despite emerging knowledge of how widespread childhood trauma is in our society, the children we meet in our practices often come to us having internalized society’s message of denial. Their demoralization and disbelief in the possibility of change often is rooted in the fact that their disclosures were not believed or, like Shawn Hornbeck, they may feel blamed for their apparent “complicity.” Often, the crimes committed against them were never prosecuted and important adults in their life failed to appreciate the harm they suffered. Discomfort with trauma can lead adults to quickly change the topic, ask doubting or minimizing questions, or challenge children about why they did not tell sooner.

Traumatized children are hyper-alert to any messages which appear to minimize or discount their experiences, and they will often angrily reject and then tune out any adults who they suspect don’t understand their suffering. Twelve-year-old Deborah, adopted from a Romanian orphanage at age 3, told me with disdain that her previous therapist had called her “a liar” when she discussed her memories of the orphanage. Upon inquiry, the therapist stated that she had responded to Deborah’s horrific memories by saying, “You were so young, are you sure you are remembering it right?” This seemingly mild but questioning response made it impossible for Deborah to trust her therapist. Children who encounter skeptical police officers, defense attorneys or department of social service workers often emerge from these interviews feeling re-traumatized by the doubting response they encounter. While most avoidance or denial of children’s traumatic experiences is inadvertent, sometimes adults have a vested professional, legal, or monetary interest, in refuting or disputing known traumatic events.

Unfortunately, there is a fervent backlash that seeks to deny or minimize the effects of trauma and sexual abuse. This denial appears to serve powerful vested interests, including defense attorneys and their defendants, as well as the organized pedophile movement, which tries to justify the abuse of children by “minor-attracted” individuals (the “neutral” term they prefer). In 1998, Rind, Bauserman and Tromovitch published an article in which they claimed to find that the sexual abuse of boys, which they re-termed “adult-child sex,” was not harmful. My colleagues and I discovered that the article was riddled with scientific reasoning errors and blatant misrepresentations of data (Dallam et al., 2001). The Rind et al. article was quickly touted by pedophiles as vindication for their lifestyle and cited in their writings to justify their sexual exploitation of children under the guise of an alternate lifestyle (Dallam, 2002).

Similar patterns of misrepresentation have been found in the writings on suggestibility of children based on sex abuse cases in daycare centers in the 1980s. Many of the convictions in these cases were overturned, and it was widely believed that suggestive interviewing of children had led to false allegations and mass hysteria. Yet, a careful analysis of actual case records revealed that claims of police and clinician misconduct were often misre-ported or exaggerated. Ross Cheit (2014) found the key that unravels this scandal of misinformation that led to a backlash against believing young children who report abuse.

The State v. Michaels trial against defendant Kelly Michaels, charged with abusing children in the Wee Care daycare center in New Jersey, was a turning point. In 1993, the New Jersey Appellate Division overturned the convictions and established the requirement for “taint hearings” to evaluate whether children’s claims are free of suggestive bias. However, a closer look at the evidence reveals “a smoking gun.” The researchers who filed a friend of the court brief for the defendant included in their brief interview transcripts that had been edited in such a way that they misrepresented interviews with the children. By deleting children’s disclosures while including interviewers’ questions after these disclosures, the edited transcripts gave the erroneous appearance that suggestive interviewing techniques were being used. The overall impression from these edited transcripts was that the interviewer was leading the child and suggesting the answers. This brief was very impactful in changing the discourse about childhood abuse, leading to the widespread misassumption that glaring errors in interviewing were the basis of convictions against daycare providers nationally.

This strong bias against believing children became codified in professional literature such as Ceci and Bruck’s (1995) Jeopardy in the Courtroom which based many of its conclusions about children’s suggestibility on these mis-transcriptions of key interviews. One could conclude that a whole science of “suggestibility” and the subsequent requirement in New Jersey of taint hearings to determine if children’s testimony was suggested is based, in part, on these misleading transcripts. These hearings have made it much more difficult to prosecute child abuse. It is my hope that, in time, the significance of this error will be exposed and some of these legal requirements re-examined.

While loud and often slickly packaged as if scientific, denials of the prevalence or the harm of abuse and trauma ring hollow, as increasingly persuasive research data document long-term health outcomes, psychological co-morbidity, and even brain impairment as a measurable effect of a variety of traumatic events.

PSYCHOLOGICAL EFFECTS OF MALTREATMENT

In a meta-analysis of 65 studies, a robust relationship was found between childhood maltreatment and neglect and dissociation in adults (Vonderlin et al., 2018).

Higher dissociation scores in adults were predicted by the earlier age of onset of the abuse, longer duration of the abuse, and the parent as abuser. This is a powerful finding of the long-lasting effects of maltreatment through the life span. Each form of child maltreatment contributes significant risk to vulnerable children, to overall psychopathology, and to dissociation in particular.

Sexual Abuse

A systematic review by Moody, Cannings-John, Hood, Kemp, and Robling (2018) found that in North America approximately 20.4% (13.2–33.6%) of girls, and 6.5% (4.0–16.0%) of boys are victims of child sexual abuse. Sexual abuse is found in all socioeconomic levels and cultures and over 90% is perpetrated by someone the child or child’s family knows (Finkelhor & Shattuck, 2012). Research suggests that sexual abuse, particularly when it is more invasive, is associated with a variety of psychiatric sequelae such as sexualized behavior and sexual risk-taking, depression, eating disorders, self-harm, drug and alcohol abuse, and significant risks of subsequent revictimization (Putnam, 2003; Trickett, Noll, & Putnam, 2011).

Finkelhor and Browne (1985) theorize that the harm of sexual abuse may relate to the stigmatizing effects of the experience, the experience of powerlessness, and the boundary violations associated with sexual abuse. It is difficult to develop a sense of self-worth and autonomy when one’s experience of one’s body is as an object of another’s pleasure. Compounding these effects are the psychological experiences of the child survivor as they internalize and react to the messages of the perpetrator. Self-justifying rationalizations are typical of the sexual offender (Courtois, 2010), such as “This is an expression of love,” “You made me do this to you,” or “This is what you deserve.”

When these rationalizations are expressed by a parent or close family member, it becomes hard for child survivors to extricate themselves from these beliefs as their attachment to the family member would be jeopardized. If even Shawn Hornbeck, who was abused by a stranger, felt this loyalty and fear of escape, imagine the bind felt by children abused by their own parents.

Trickett et al. (2011) followed 84 sexually abused girls for 23 years and found significant physiological sequelae of sexual abuse, including obesity, gynecological abnormalities, including early onset of puberty, major illnesses, increased health care utilization, cognitive deficits, abnormal levels of the stress hormone cortisol, and disruption of the hypothalamic-pituitary-adrenal axis. Of significant concern, the children born to abused girls were also at risk, with more referrals to child protective services, primarily for neglect. In addition, sexually abused children are at risk for further sexual victimization and when victimized suffer more severe consequences (Briere, Runtz, Rassart, & Godbout, 2020). Research on sexually abused children and teens documents high levels of dissociation in this population (Bonanno, Noll, Putnam, O’Neill, & Trickett, 2003; Collin-Vézina & Hébert, 2005; Hagan, Gentry, Ippen, & Lieberman, 2017; Macfie, Cicchetti, & Toth, 2001) with dissociative symptoms related to early onset of sexual abuse, multiple perpetrators (Trickett et al., 2011), and duration of sexual abuse (Hébert et al., 2017). Dissociative symptoms are also associated with risk-taking behavior (Kisiel & Lyons, 2001), self-harm (Hoyos et al., 2019), affect dysregulation, and disorganized attachment (Hébert, Langevin & Charest, 2020).

A new form of sexual exploitation that therapists are just beginning to see in their practices is children abused for the purpose of creating child sexual abuse imagery (CSAI). This term has been used to replace the older term “child pornography” which people often understood as simply nude or suggestive pictures of children. The added experience of having been victimized “digitally” significantly adds to the victims’ posttraumatic stress and negatively impacts their quality of life and subjective well-being (Hamby et al., 2018). These digital images often portray scenes of horrific sexual and physical torture. The trend has been toward portraying younger and younger children and subjecting them to the most horrific acts imaginable. In a survey by Gewirtz-Meydana, Walsh, Wolak, and Finkelhor (2018), 22% of victims whose images were found online reported their abuse began at age 2 or younger.

The most severe form of child sexual abuse imagery exploitation has been termed “hurtcore” (Maxim, Orlando, Skinner, & Broadhurst, 2016; Daly, 2019). Arrests in Australia reveal that networks of perpetrators interested in these materials may establish communities in which they trade images and promote the trafficking of live children often exploiting them through streaming sexual torture scenarios in real time. These children suffer with the awareness that depictions of their abuse r...