Counselling Skills for Working with Trauma

Healing From Child Sexual Abuse, Sexual Violence and Domestic Abuse

Christiane Sanderson

• Editorial: Jessica Kingsley Publishers
• Año: 2013
• ISBN:
  9780857007438
• Categoría: Psychology
• Categoría: Psychotherapy Counselling

Counselling Skills for Working with Trauma is a practical, introductory guide to counselling survivors of child abuse, neglect, rape, sexual violence, sexual trafficking, religious sexual abuse, and domestic abuse.

Written in an accessible style, it provides a comprehensive introduction to complex trauma accompanied by advice on how to create a safe environment in which survivors can learn the skills to restore control over trauma symptoms, to aid healing and post traumatic growth. The book covers all of the key principles including: understanding the role of dissociation in complex trauma; the role of attachment; managing flashbacks, panic attacks, nightmares and dissociation; responding to shame and guilt; managing relationships; and the impact of working with complex trauma. It explores how practitioners can work more effectively with trauma, and offers techniques and skills which can easily be integrated into different therapeutic models.

Featuring highlighted top tips, common pitfalls and a range of exercises, this is an essential guide for all professionals working with child and adult survivors of trauma.

Part 1

UNDERSTANDING
COMPLEX TRAUMA

1

UNDERSTANDING TRAUMA
AND COMPLEX TRAUMA

Trauma is commonly defined as exposure to actual or threatened death, serious injury or sexual violation (DSM-V, APA, 2013) in which intense fear, horror or helplessness predominates. This can occur either through one single event or multiple and repeated traumatic events. Complex trauma is usually associated with prolonged, repeated traumatic experiences which involve multiple violations such as sexual assaults, physical violence, emotional abuse and neglect, often committed by someone known to the victim. In contrast to a single traumatic event, the repeated betrayal of trust, in which ‘abuse masquerades as protection or affection’ (Sanderson, 2010a, p.72) gives rise to a range of symptoms such as dissociation, alterations in sense of self, and a fear of intimacy in relationships.

This chapter explores the nature of trauma and complex trauma and how these impact upon individuals. The main focus will be on complex trauma and the range of symptomatology associated with repeated trauma within dependent relationships in which there is no escape. It will also present the current Diagnostic and Statistical Manual (DSM-V, APA, 2013) criteria and symptoms for Post-Traumatic Stress Disorder (PTSD) and symptoms associated with complex trauma.

WHAT IS MEANT BY TRAUMA?

There is often considerable variation in what is meant by trauma amongst clinicians, researchers, practitioners and survivors of trauma. In the recent revision in the American Psychiatric Association’s Diagnostic Statistical Manual V (APA, 2013) criteria for trauma leading to PTSD now include not only direct exposure to actual or threatened death, serious injury or sexual violation, but also the witnessing of such traumatic events, learning about such events happening to a close family member or friend, and experiencing repeated or extreme exposure to aversive details of traumatic events by emergency workers or police officers (APA, 2013). This last category equally applies to practitioners who specialise in working with survivors of trauma (see Chapter 24).

While this revision includes not just trauma through combat or natural disasters, but also sexual violation, it does not fully explain the impact of pervasive and repeated physical, sexual or psychological violations, or the habitual unpredictability and lack of control within attachment relationships such as child physical abuse (CPA), child sexual abuse (CSA), domestic abuse (DA), or institutional abuse. It also does not account for the complexity of abuse by those who have power and authority over the individual such as religious or faith leaders (Sanderson, 2011), cult leaders, or abuse by professionals such as doctors, psychotherapists or counsellors (Sanderson, 2010a). As a result the current criteria do not unravel how persistent threats to psychological integrity from prolonged abuse within an attachment relationship can undermine self-structures and related mental capacities.

Several clinicians and researchers (Herman, 1992b; Rothschild, 2000; Sanderson, 2010a; Terr, 1991) have highlighted the significant differences between a single event trauma, what Terr (1991) refers to as Type I Trauma, and multiple or Type II Trauma, especially in terms of impact and long-term effects. According to Terr (1991) Type II Trauma is associated with much greater psychobiological disruption, including complex post-traumatic stress reactions, dissociation, alterations in perception, dissociative amnesia for past and present experiences, memory impairment, loss of continuity and loss of meaning.

Rothschild (2000) further distinguishes between Type II Trauma and degrees of resilience. According to Rothschild (2000), Type IIA Trauma consists of multiple traumas experienced by individuals who have benefited from relatively stable backgrounds, and thus have sufficient resources to separate individual traumatic events from one another. In contrast, Type IIB Trauma consists of multiple traumas which are so overwhelming that the individual cannot separate one from another. Type IIB Traumas are further divided into Type IIB (R) in which the person has experienced sufficient stability to develop resources but the complexity of traumatic experiences are so overwhelming that resilience is impaired. In contrast, in Type IIB (nR) Trauma the individual has never developed resources for resilience. The latter is characteristic of survivors of complex trauma who have a history of childhood trauma such as CPA or CSA, and adult re-victimisation.

TRAUMA WITHIN ATTACHMENT RELATIONSHIPS

Repeated acts of violence, abuse or humiliation within attachment relationships can have more pervasive immediate and long-term effects due to the aversive dynamics such as the betrayal of trust, violation of dependency and protection needs and the severing of human connection, which threatens the sense of self and self-identity. Such failures in attachment and lack of protection when most needed can result in disruptions to, or fragmentation of personality, resulting in a chronic sense of emptiness, future relationship difficulties, and traumatic loneliness.

Trauma within attachment relationships in which the person is dependent on the abuser to satisfy basic human needs such as safety and protection, gives rise to a range of psychobiological defences that can result in dissociation and alterations in perception. To reconcile the paradox of abuse within a caring relationship or ‘Knowing what you are not supposed to know and feeling what you are not supposed to feel’ (Bowlby, 1988, p.99) survivors have to deny the traumatic nature of the abuse in order to hold onto a positive image of the abuser on whom they depend to have basic human needs met. In addition, when the abuser wields power and authority over the individual, acknowledging the abuse can have terrifying consequences: it can feel safer to deny the traumatic nature of the experience. This can lead to traumatic bonding (see Chapter 4, pp.61–2), confusion and distortion of reality.

In addition, the constant threat of physical or psychological annihilation, unpredictability and lack of control forces the individual to disown basic human needs and to deny any experience of vulnerability. Dehumanising the individual and distorting their reality prevents the individual from legitimising or naming the experience as abuse or trauma. This is further compounded when violations are initially not perceived as painful, terrifying or traumatic due dissociation, the distortion of reality by the abuser, or normalisation. Many abusers coerce victims through establishing a ‘special’ relationship in which sexual contact or physical punishment is presented as normal, making it hard to define as abuse or trauma. Awareness of the abusive nature of such coercion may not penetrate conscious awareness until much later when the person is in a place of safety and is able to reflect on their experience, or through cognitive reappraisal.

In the absence of being able to validate the trauma it becomes difficult to generate meaning, or make sense of experiences. As a result all relationships are seen as dangerous, a source of anxiety or terror and anticipated re-traumatisation, making it hard to trust and connect to others, including professionals.

COMPLEX TRAUMA

Despite significant differences between single event and multiple prolonged trauma, and proposals for a separate category of complex traumatic stress disorder (Herman, 2006), the APA have not included this in DSM-V as a separate, stand-alone diagnostic category. The revised International Classification of Diseases 10 (ICD 10, WHO, 2007) has taken into account both prolonged trauma and the delay or protracted responses to it in their categorisation of PTSD ‘…as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone…[that] may follow a chronic course over many years, with eventual transition to an enduring personality change’ (www.who.int/classifications/icd/icdonlineversions/en).

Despite not being included in DSM-V (APA, 2013) there is considerable clinical evidence that, ‘Survivors of prolonged abuse develop characteristic personality changes, including deformations of relatedness and identity…’ (Herman, 1992b, p.379) and that conceptualising these dynamics within complex trauma aids clinicians in understanding the impact of pervasive and adverse traumatic events such as repeated sexual or physical abuse both in childhood and adulthood, committed in the absence of adequate emotional or social support. As such complex trauma more adequately highlights the symptoms seen in cases of repetitive and inescapable abuse in intimate relationships such as CPA, CSA, DA, elder abuse, institutional abuse, sexual slavery, or those held in ‘captivity’, or in thrall to their abuser who are not accounted for in current formulations of post-traumatic stress responses (Sanderson, 2010a).

POST-TRAUMATIC STRESS DISORDER (PTSD)

About one third of survivors of trauma and complex trauma develop symptoms of PTSD and it is more commonly diagnosed in females (Chu, 2011), probably due to females seeking help for their symptoms, while males tend to mask or regulate their symptoms through self-medication and the use of alcohol or drugs. The main criteria for the...