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Table of contents
- Approaches to Talking Therapy
- Trauma & PTSD
- Trauma & PTSD | Resilient Brain Project | Resilient Brain Project
- Self-Care, Self-Esteem and Other Key Issues for Abuse Survivors
Jane broke the family "rules" by telling. Afterward she felt frightened and thought she had done something wrong. When her therapist failed to mention the memory, she began to think that she had been exaggerating and that the incident wasn't such a big deal. This shift can often be difficult for clinicians who have been trained to view neutrality and therapeutic distance as a valuable asset and who may fear creating an overly involved or overly intrusive environment.
While a significant level of emotional involvement is an essential ingredient in the therapeutic relationship with victims of childhood abuse, over-involvement on the part of the therapist must be monitored as well. Active engagement requires the therapist's willingness to initiate interaction with, and attune, to each survivor. The therapist must engage in an active process to develop a relationship that fits the particular individual's needs, rather than one which simply reflects the therapist's assumptions of the "correct way to proceed. In order to facilitate the client's reconnection to self, the therapeutic relationship must offer both containment and bridging.
Throughout the treatment process, and especially in the face of previously repressed memories and the powerful affect and ego disorganization that accompany them, the therapeutic relationship needs literally and symbolically to provide a containment or holding environment for the client. During these periods the therapeutic work must foster active support and interaction that responds to the client's regressive needs.
As Susan was returning home from her therapy session she saw an older man walking in the street. She began to have intrusive images followed by a panic attack. She called her therapist, and at his suggestion wrote me images. He told Susan to seal them in an envelope and mail it to him to keep until her next session. After mailing the letter Susan was able to return to her daily routine. The fragmentation resulting from the use of denial and dissociation creates other difficulties in the treatment process.
Approaches to Talking Therapy
The client's ability simultaneously to retain both a cognitive account and a felt sense of the abuse experiences can vary not only from moment to moment within the session, but also from session to session and from one context to another. Through consistent attention and follow up, the therapist temporarily becomes the bridge between the pieces of self and experience that the client has split off, gently and persistently holding the reality of the traumatic experiences throughout the client's confusion, self-doubt, and forgetting. The therapeutic relationship must also address the repair of the interpersonal damage survivors suffer as a result of the childhood traumas Kaufmann, A major goal of treatment, as Catherall notes, is "the re-establishment of a trusting relationship between the victim and his or her most immediate experience of the human community, the therapist" p.
The re-establishment of trusting relationships requires this issue to be addressed explicitly and repeatedly over time as the client and therapist actively engage in a relational process that counters the client's early experience of coercion and betrayal in primary relationships. The therapeutic relationship must withstand and remain constant in the face of conflict, disappointment, disillusionment, the projections and demands of transference and counter-transference reactions, and often profound ambivalence to both the therapeutic process and relationship. The role of the therapist's own feelings takes on a special importance as families of adult survivors often responded to the abuse with blindness, silence, or discounting.
The experience of the therapist's normal, human emotion in response to the trauma can become an important part of repairing the interpersonal damage as it demonstrates that what happened to the survivor matters and is significant to someone. This expression of emotion by the therapist, however, challenges traditional notions of therapeutic boundaries, and must be accomplished in such a way that the therapist's needs and emotions to not become the focus of the therapeutic process.
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Sympathy and good intentions alone are not sufficient and cannot substitute for clinical understanding and effective intervention in treatment with survivors of childhood abuse. However, respect and kindness are important ingredients of the therapeutic relationship as these attitudes facilitate important corrective functions in treatment. These are qualities that are singularly lacking in abusive families. Often, even well-planned and technically correct interventions will be ineffective unless they are executed within the context of a therapeutic relationship that conveys kindness and respect.
The paradigm of "learned helplessness" Seligman, has been used in some instances Flannery, ; Walker, to understand both the feelings of depression, helplessness, and low self-esteem, as well as the increased risk of revictimization, which often persist long after incidences of childhood abuse. These authors would argue that it is not so much learned helplessness that determines the impact of the trauma on individuals, but rather, "learned hopelessness. In the therapeutic process with abuse victims who, as vulnerable children, suffered unendurable experiences, providing hope becomes an important task.
As Browne explains, "if a pathway to improvement appears to be non-existent, victims stop talking.
The intentional use of touch by the therapist is a controversial and sensitive issue in psychotherapy. This is especially true in working with survivors of childhood abuse whose history of touch is a negative one in which touch has been sexualized, intrusive, and in some instances assaultive. Although it is not essential that the therapist directly touch a client in order to attend to or alter the emotional processes that emerge in treatment, the skillful use of direct physical contact with victims of sexual abuse can, in many instances, offer a powerful treatment intervention. The appropriate use of touch, within the context of an ongoing therapeutic relationship, can offer contact, provide nurturing, convey safety, and encourage increased self-awareness.
Physical contact can facilitate a deepening of the client's affective experience and provide a connection to the trauma experiences that may be difficult to achieve with words alone.
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Within the context of the therapeutic relationship, the client can experience respectful, engaging touch in sharp contrast to the abusive, uncontrollable touch associated with the original trauma. Touch used as a therapeutic intervention covers a wide spectrum of techniques. Therefore, the question of which uses of touch are most effective in the treatment of abuse victims becomes an important one. While numerous specialized therapies Boadella, ; Lowen, ; Reich, offer approaches which are body-centered and use therapeutic touch as a matter of course, more conventional psychotherapies provide no systematic approach for the use of touch by the therapist.
These forms of touch heighten self-awareness and, when used as an extension of the therapeutic relationship, are the most appropriate for survivors. The use of therapeutic touch is not appropriate for all clients, and each case must be individually evaluated.
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The management and integration of affect, both within the process of remembering the traumatic experiences as well as in current life, is crucial in the resolution of childhood abuse. An intensity of affect or an utter lack of affect may accompany the client's remembering and disclosing of abuse experiences.
Victims of sexual abuse may periodically experience episodes of intense affect, which are spontaneously triggered by external life situations. The emergence of strong, sometimes uncontrollable, affect can be deeply disconcerting to both the client and the therapist Wilson, These symptoms, which are consistent with PTSD, may be mistaken for decompensation Gelinas, and result in a therapeutic decision to discontinue direct work at an affective level.
In response to this intense affect, clinicians have occasionally erred in the opposite direction, encouraging abreaction through the use of interventions that focus on expression and catharsis rather than self-connectedness. Interventions geared primarily toward affective expression and catharsis are both overly stimulating and too intrusive. Elizabeth described a previous therapy experience: However, contradicting my own assumptions about therapy, no number of catharses seemed to make any difference in my depression or my increasing anxiety with my therapist.
Instead of healing the abuse through the transference, we were perpetuating it. Attempts to manage the intensity produced by these overstimulating interventions usually result in the client's increased need to use denial and dissociation. This can cause sudden and marked changes in the therapeutic relationship, as the client may become increasingly compliant or may begin to distance in the face of the overly stimulating and intrusive techniques.
The therapist must directly encourage the clients' gradual acceptance and deepening of affect to facilitate the integration of the abuse experiences. This includes both the affect resulting directly from the abuse and that which is a reaction to the environment's failure to protect and comfort. This affect must be reconnected to the content of the trauma in order for the survivor to make meaning of their experiences. This integration process requires the establishment of an "affective edge.
Trauma & PTSD
Working at the affective edge provides an avenue for accessing affect and deepening the client's connection to self and personal history, thus permitting reworking of traumatic material and its integration into current life. The quality of the therapeutic relationship is crucial in establishing and maintaining the affective edge. The therapist's direct stance and attitude facilitates an interruption in the client's use of denial, intensifies emotional contact allowing access to the traumatic material and offers containment which facilitates the client's increasing tolerance of the affect.
In such instances the treatment must be slowed. Until the client's connection to self can be re-established, the therapist literally becomes the living record of the therapy by maintaining the reality of, and appropriate affect related to, the sexual abuse. Recovering memories of the childhood trauma is not an end in itself. However, for the survivor of sexual abuse, such memories are a crucial part of reconstructing and reconnecting to one's own personal history.
Despite the defensive forces of denial and dissociation, there is, as Chu describes, "an opposing need on the part of the psyche to force repressed material into consciousness" which can take on an "almost biological urgency" p. Consequently, a client's memory of childhood abuse may contain ideas and fragments derived from later perceptions and experiences.
Accuracy may also be affected as different events are not necessarily stored in memory as separate occurrences. Similar but distinctly separate events may be combined into a condensed version of reality Neisser, This condensation can lead to confusion when a survivor of abuse tries to reconstruct specific instances of the trauma.
The traumatic memory may include details from a number of different places, ages, and in some instances different people which are combined into a single scenario. In addition to the impediments inherent in any memory retrieval process, victims of childhood abuse may have additional difficulties as a result of the trauma experiences. Terr describes the amnesia and fragmentation that result from the repetitive, intrusive trauma that is typical in abusive families. By way of contrast, the details of "single-blow" trauma are frequently remembered in vivid and coherent detail.
The existence of inaccuracies therefore, does not invalidate the essential truth of what is recalled. With survivors of childhood abuse the inaccuracies and confusion concerning the details of the trauma in no way diminish the reality of the abuse itself.
The ability of an individual to gain access to trauma memories is primarily determined by three factors. Perhaps the most significant factor is the individual's current ability to tolerate the particular content or meaning of the abuse, an experience so unendurable in childhood that it precipitated the original memory loss. Often the client's tolerance level significantly increases as safety and consistency are established in the context of the therapeutic relationship.
A second factor, the lowering or softening of the individual's defenses Courtois, , also increases access to trauma memories. This softening may occur as the result of deliberate efforts in the therapy process or spontaneously as the result of a life crisis, changes in life style sobriety, weight loss, etc. Finally, a third factor which facilitates memory retrieval is the presence of external "triggers" Olio, A variety of stimuli can serve as triggers.
It could be a current instance of revictimization or a developmental event such as the birth of a child, a child's reaching the age of the parent's victimization, a child's leaving home, etc. Or the trigger could simply be any change which increases the emotional intensity of life.
This can be either a negative event, such as a disappointment, failure, or loss, or a positive change, such as a career success, falling in love, etc. Sometimes trauma memories are triggered by medical or dental procedures. In other instances, previously neutral stimuli which resemble some aspect of the abuse, or the disclosure of others family, friends, group members, media accounts can also trigger memories. The use of triggers to facilitate the return of traumatic memories is highlighted by an understanding of the distinction between two different retrieval processes—recognition and recall.
Recognition is a simple, one-step process in which the individual determines if an externally provided stimulus is familiar. Recall, a more complex, two-step process, requires the individual to generate a possibility and then determine if it is familiar. Denial and dissociation inhibit the consideration of abuse, thus reducing the likelihood that survivors' will internally generate the possibilities required to initiate the recall process.
The recognition process, which utilizes external cues, provides greater access to the trauma memories. As Anderson observes, "we can recognize many things we can't recall … recognition often works even when recall fails" p. During the therapy process, the therapist may wish to utilize specific therapeutic modalities e.
A personally reconstructed history, with its' primary focus on the meaning to the individual rather than the on the literal facts, is sufficient for addressing most issues during treatment. However, because of the years of silence, the family denial, and the victim's own disconnection from personal history, in the therapeutic effort to resolve abuse, the question "Did this really happen? Therapeutic validation requires an acknowledgement of the abuse as an external reality.
No therapeutic process can ever reconstruct childhood in absolute, literal detail. However, in the treatment of adult survivors it is crucial for the client to reconstruct as clearly as possible, a "picture" of the abusive events and the context which enabled them to occur. What happened and how it happened needs to be uncovered, understood and felt. Despite the inaccuracies and distortions inherent in all memory retrieval, the trauma memories need to be recovered and re-experienced with appropriate affect.
The therapist must continually acknowledge the reality of the abuse for the trauma memories to continue to unfold and for the survivor's trust in his or her perceptions to be restored. The past twenty years have seen dramatic changes in the awareness and understanding of the long-lasting effects of childhood sexual abuse.
Survivors of abuse, who as children suffered at the hands of people in positions of love and authority, enter psychotherapy, as adults, with special needs. Childhood abuse often results in emotional numbness and disconnection, diminished vitality, and a fragmented sense of self. Victims of abuse continuing patterns of denial and dissociation into adult life can results in partial or total memory loss of both the traumatic events and important segments of their histories.
Frequently survivors are left doubting their own reality. Addressing these issues often requires a shift in the nature and structure of the therapeutic relationship. The authors advocate the development of an active, affective, therapeutic relationship, as the foundation for treatment. Such a relationship creates a safe and responsive environment which allows for accessing, reworking, and integrating the traumatic material.
It provides a vehicle to facilitate both the client's reintegration of self and the re-establishment of trustworthy relationships with others. This article offers a conceptual framework within this relational context for direct attention to and intervention with the trauma memories and the accompanying affect.
The integration of sexual abuse into adult life requires survivors to fully acknowledge the painful reality of their childhoods and the resulting damage done to them. They must re-own their feelings of helplessness, fear, desperation, and rage without splitting off parts off themselves to tolerate these feelings. The goal of the therapeutic process, then, is not primarily "overcoming the past" or expression and catharsis regarding the past, but rather one of encouraging emotional vitality and personal integration. If the therapeutic relationship can provide enough safety, containment and emotional contact, survivors can transform their experiences of abuse.
They can regain a sense of empowerment while reclaiming all the parts of themselves and their experiences. Cognitive psychology and its implications. The impact of incest trauma on ego development. Treating the dissociative process in adult victims of childhood incest. Social Casework, 66, An introduction to biosynthesis. The other side of child abuse. Psychoanalysis and human idiom. Feminist, non-sexist, and traditional models of therapy; implications for working with incest.
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Trauma & PTSD | Resilient Brain Project | Resilient Brain Project
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Recovery from childhood sexual abuse. One of Ken's passions in life includes training national leaders, hiking and eating ethnic foods.
Self-Care, Self-Esteem and Other Key Issues for Abuse Survivors
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