A study by Draper et al. (2007) found that of 21,000 people over the age of 60 from 5 Australian states, 6.7% reported having been physically abused, 6.5% sexually, 10% reported either and 3% both (Draper et al., 2007). Research on a sample of randomly selected Australian women revealed that 20% of participants had experienced childhood sexual abuse (Fleming, 1997). Of those women, 71% were aged less than 12 years at the time of their abuse and only 10% of cases were ever reported. Andrews, Gould and Corry (2002) reported on the overall findings of seven studies and found that 5.1% of males and 27.5% of females had experienced some level of child sexual abuse.
Statistics suggest that child abuse is on the rise, but reporting may have increased rather than there being an actual increase in incidence. Perhaps adults are simply more aware of the warning signs of abuse now than ever before.
2. THE COMMON STORY
Andrews et al. (2002), who reported on the overall findings of seven studies, found that the onset of sexual abuse occurred at a mean age of 10. In 75% of cases the offender was known to the child, and in 40% of cases a family member was the offender.
A study by Palmer, Brown, Rae-Grant, & Loughin (2001) with 384 survivors of childhood abuse identified that most survivors reported a combination of abuse types: physical, emotional and sexual (45%); physical and emotional (21%); sexual and emotional (17%); sexual only (11%) and emotional only (6%). Survivors who could recall the age of onset of the abuse had been very young (between 4 and 6). The reported perpetrator were biological fathers (34%), biological mothers (19%), stepfathers, adoptive fathers and foster fathers (8%); stepmothers, adoptive mothers and foster mothers (5%); both parents equally (7%); other relative (14%); and siblings (10%).
A study by van Loon & Kralik (2005a) with female survivors of child sexual abuse found that child sexual abuse survivors is often interwoven with emotional abuse and physical violence. Many participants in this study experienced assaults within their childhood families which were not isolated events, but sustained patterns of behaviour, endured over many years. Most women recalled their earliest memories of sexual abuse between the ages of 5 and 8 years. Participants’ backgrounds varied across rural, remote and metropolitan settings and all social strata were represented, including professional, paraprofessional and working class families.
There was an over-representation of perpetrators who were in positions of legally sanctioned authority. The participants in this study reported compounding social issues within the childhood family that included fragmentation of the family through divorce, family violence, alcohol and drug addictions, and mental illness. In most cases the family presented to the outside world as “normal”. Family relationships were characterised by intimidation, fear, shame, blame, secrecy and isolation, to avoid exposing the family to scrutiny. The victims were silenced by fear of the consequences of divulging the family secret. Perpetrators made excuses to avoid taking responsibility for their abusive actions and most commonly the child was blamed for somehow provoking, or enjoying the abuse.
Unfortunately when children do tell, and the offending perpetrator denies their actions, it is often the perpetrator who is believed rather than the child. If the adult to whom the child discloses does not take any action the child may conclude that he/she is not worthwhile, or must be to blame. It reinforces the child’s distrust of adults and causes more entrenched silence, isolation, internalised anger, which quickly leads to despair and possibly to mental illness. Survivors suggest that while children need to be educated about stranger danger, most abuse is perpetrated by a person the child knows. Consequently the child also needs to be taught to say ‘no’ to uninvited and unwanted behaviours. However children often find it almost impossible to have a voice to which their perpetrator/s will listen (van Loon & Kralik, 2005a).
3. CHILDHOOD TRAUMA
Trauma is not limited to surviving life-threatening experiences. For a young person, trauma may be experienced in the form of separation from parents, looking into the eyes of a depressed mother, or being in a household with high level marital tension. For an adolescent, chronic stress and trauma may come from the incessant teasing of peers or taking care of the needs of an alcoholic parent (Cozolino, 2002). It seems that even an unborn child can experience stress as the result of the shared biological environment with its mother (Cozolino, 2002). Tests have found that foetuses express a biological response indicative of a stress response well before birth (Gunnar, 1998).
When humans are young, their world often revolves around their parents or care-givers. They are the source of safety and security, of love and understanding, of nurturance and support. A child experiencing trauma or abuse develops strategies, which become coping mechanisms to enable day-to-day functioning. They help the child detach from the emotional and physical pain of events, especially it continues over a long period of time (Henderson, 2006).
Researchers have observed the ways people respond to dangerous or abusive environments. These neurophysiological physical and mental responses to threat are of two main types:
- hyper-arousal continuum ('fight or flight'), i.e., vigilance, resistance (freeze), defiance, aggression
- dissociative continuum, i.e. avoidance, compliance (appease), dissociation, fainting (Perry, Pollard, Blakely, Baker, & Vigilante, 1995).
In the face of persisting threat, a child will either move along the hyper-arousal continuum (the child's version of 'fight or flight') or into the dissociative continuum (Perry et al., 1995). The individual response will depend upon the age of the child and the nature of the threat. The younger the individual, the more likely he/she is to use dissociative adaptations rather than hyper-arousal responses (Perry et al., 1995).
1. HYPER-AROUSAL CONTINUUM
1. 'Fight or flight'
The most familiar set of responses to threat are 'fight or flight' reactions i.e. an instinctive response to try to overcome the danger (fight) or run away from it (flight). Infants and children however are often rarely capable of being able to either fight or flee.
‘Fight or flight’ are not the only response-sets to threat. In the initial stages of distress, a young child will use vocalization, i.e. crying, to alert a caretaker that he/she is under threat. This is a successful adaptive response if the caretaker takes appropriate action and fights for, or flees with, the child. If a child’s cries for help are ignored and no help arrives, or if the trauma is being inflicted by the caregiver, the child may shift from hyper-arousal to dissociation (Perry et al., 1995).
Protracted threat may cause a child to ‘freeze’. The adaptive advantage of this response is clear: being still or quiet means one is less likely to be seen or heard, and gives one time to prepare to respond to a potential threat (Cozolino, 2008). Internally, the freeze response increases anxiety and decreases cognitive processes so that it allows one to ‘figure out’ how to respond (Perry et al., 1995). Being motionless is an effective form of camouflage which reduces the likelihood of attracting a predator.
Children who have been traumatized will often use this freezing mechanism when they feel anxious (Perry et al., 1995). In situations where the child feels anxious or out of control (e.g. a family visit) the traumatized-child may cognitively (and often, physically) freeze. In such cases the child may act as if he/she hasn’t heard or ‘refuses’ to follow an adult’s instructions. Such non-compliance forces the adult to increase the ‘threat’ by ramping up the instructions. This increased ‘threat’ makes the child feel even more anxious and out of control. The more anxious the child feels, the more readily the child will move from anxious to threatened, and then from threatened to terrorized. If sufficiently terrorized, ‘freezing’ may escalate into dissociation (Perry et al., 1995).
2. CHILDHOOD COPING STRATEGIES
Avoidant Coping Strategies:
A child who experiences extreme trauma or abuse has few coping mechanisms at his/her disposal. Understanding and integrating the experience may overwhelm the child’s coping mechanisms. In the absence of effective coping skills, the child's most best option for psychologically surviving is to dissociate or shut off the experience from his/her consciousness (Henderson, 2006; Perry et al., 1995).
Dissociation refers to the mental processes that create a lack of connection in the person’s thoughts, memories, feelings, actions or sense of self (Amir & Lev-Wiesel, 2007; Reber & Reber, 2001). Traumatized children use a variety of dissociative techniques. In dissociating, the child (or adult survivor) alters the normal links between thoughts, feelings and memories (Briere, 1992) and so decreases awareness of, or numbs the pain of distressing events (Putnam, 1985). Dissociation is commonly referred to as being ‘spaced out’, ‘blocking things out’ and ‘being out of touch with one's emotions’. Infants and young children commonly employ a variety of dissociative responses such as: numbing, avoidance, and restricted affect. Children report going to a ‘different place’, ‘assuming the persona of heroes or animals’, a sense of ‘watching a movie that I was in’ or ‘just floating’. Observers will report these children as numb, robotic, non-reactive, ‘day dreaming’, ‘acting like he was not there’ or ‘staring off into space with a glazed look’ (Perry et al., 1995).
Splitting is often related to early abuse and appears to be a mechanism by which people can preserve some semblance of happiness in the face of very negative experiences. Splitting refers to the failure to integrate the positive and negative qualities of self or others into cohesive images (Mounier & Andujo, 2003). People with split representations struggle with highly polarized ‘black or white, but not grey’ views of others and self; people are viewed as either entirely good or bad (Dombeck, 2008; Reber & Reber, 2001). Originally, this idea was used to describe how a child deals with the presence of both good and bad in an abusive parent by creating distinct categories in their mind between good mother/ father or bad mother/ father (Mollon, 2002).
3. Fragmentation of personality
When childhood trauma or abuse is chronic the personality becomes organised around the central principles of fragmentation because fragmentation serves to keep the trauma out of conscious awareness (Herman, 1992).
Childhood trauma and abuse often violates the trust which forms the core of the child’s relationship with the world. The child’s attempts to reorganize his/her understanding of his/her world often exceed his/her cognitive-affective abilities. Rather than experience the complete cognitive paralysis or disintegration which can occur from such a severe disruption to the child’s world, the child uses denial, a defence mechanism that simply denies thoughts, feelings, wishes or needs that cause anxiety. Denial seems to be the mind’s way of staving off complete dysfunction precipitated by overwhelming trauma (Walker, 1994). Denial may enable an individual to survive and function until a time at which he/she is able to come to terms with the event. In this context the term ‘denial’ describes unconscious operations that ‘deny’ that which cannot be dealt with consciously (Reber & Reber, 2001, p. 187).
5. Forgetting: Recovered memories and traumatic amnesia
Adults who recall traumatic events from their childhood, previously unavailable to recall are said to have “recovered” or “repressed” memories. This is also called ‘traumatic amnesia’. Thomson (1995) explains repressed memory as “an unconscious mechanism that protects the ‘self’ from being overwhelmed by the memories of the traumas by quarantining those experiences from consciousness” (p. 97; cited in Henderson, 2006). Traumatic amnesia may last for hours, weeks or years and recall can be triggered by sensory or affective stimuli reminiscent of the original event.
Traumatic amnesia and delayed memory retrieval of traumatic events has been widely documented for almost 100 years, and was scientifically accepted in the context of war, accident or disasters (van der Kolk & Fisher, 1995; cited in Henderson). The concept only became controversial when it referred to child sexual abuse (Henderson, 2006).
By the mid-1980s, a significant body of research had built up indicating that many adult survivors of childhood abuse also suffer from traumatic amnesia. Many people abused in childhood do not remember anything about their experiences for many years, whilst others recall some but not all of the details of their abuse (Dallam, 2001). Extensive research on traumatic amnesia points to the significance of the victim's age at the time of the abuse as well as the duration of the abuse. More recent evidence suggests that amnesia is more likely to occur when the child is dependent on the abuser for survival (Henderson, 2006).
One of the most definitive studies on delayed recall was a non-clinical sample of adult survivors whose sexual histories had been documented at the time of the abuse (William, 1994). Between 1973 and 1975, 206 girls aged ten months to twelve years had been examined after a report of sexual abuse. Seventeen years later, 38% of 129 of the 206 subjects (i.e. those that could be located) had not recalled the abuse when interviewed.
When avoiding reality becomes impossible, children may construct a rationale to justify their abuse. One common reaction is that children believe they are bad and deserve to be punished i.e. if, ‘she is bad and can become good’, then there is some meaning and hope for the future (Herman, 2001; cited in Henderson, 2006). To maintain hope and meaning, a child will often preserve faith in her/ his parents or caregivers, constructing explanations which absolve them from blame and responsibility and so accommodate primary attachment to her parents (Henderson, 2006).
Minimisation is the reduction of an experience to the smallest possible effect (Ostler, 1969). It is often used as a coping strategy for children surviving abuse when denial fails (Henning, Jones, & Holdford, 2005). For example, ‘My uncle does hit me occasionally, but I’ve been through far worse”.
3. Please or Appease Strategies
- Trying to be good. Another common coping strategy that children in abusive environments employ is to adopt pleasing or appeasing behaviours (Mannen, 2006). As Herman (1992) explains, many children, convinced of their powerlessness and the futility of resistance, develop a belief in the perpetrator’s absolute powers over them. The child tries to prove his/her loyalty and compliance and gain control in the only way possible, by trying to ‘be good’ (Herman, 1992).
- Seeking affection. Unable to establish a sense of safety, abused children frequently seek external sources of comfort and solace. Abused children often paradoxically seek the affection of the very individuals who abuse them. The underlying fragmentation becomes central to personality organisation, preventing integration of knowledge, memory, emotional states and bodily experience (Henderson, 2006).
1. COPING/DEFENCE STRATEGIES USED BY ADULT SURVIVORS
Defence mechanisms/coping strategies adopted during childhood are often used in adulthood e.g. the tendency to dissociate. The use of ‘childhood’ coping strategies can impair the development of more adaptive social, cognitive, and emotional coping mechanisms for adult life as well as the sense of self required for the successful negotiation of life difficulties (Briere, 2002). Adult survivors often continue to use their childhood avoidant coping strategies (van Loon & Kralik, 2005c). The adult survivor becomes the fighter, the accommodator, the escape artist, the victim, the denier, the over-achiever, and the ‘pleaser’ (van Loon & Kralik, 2005c).
A study by Ward (1988) into the different ‘defence mechanisms’ used by adolescent victims of sexual abuse identified the following core defences:
- emotional insulations (discussion of victimisation in a detached manner and/or emotional withdrawal from painful or potentially painful relationships)
- rationalisation (providing reasons and/or justifications for the abuse) and intellectualisation (managing the stressful situation as an abstract problem requiring analysis)
Research consistently shows that less adaptive coping responses (eg. avoidant coping) contribute to poorer outcomes (Futa, Nash, Hansen, & Garbin, 2003).
Morrow and Smith (1995) suggested that strategies used by survivors of childhood abuse can be conceptualised as:
- Keeping the survivor from being overwhelmed by threatening and dangerous feelings
- managing helplessness, powerless and lack of control
Strategies used to keep from being overwhelmed by threatening and dangerous feelings:
- Reducing the intensity of troubling feelings
- Avoiding or escaping the feelings
- Exchanging the overwhelming feelings for other, less threatening ones
- Discharging or releasing feelings
- Not knowing or remembering experiences that generated threatening feelings
- Dividing overwhelming feelings into manageable parts
Strategies used to manage helplessness, powerlessness and lack of control:
- Creating resistance strategies
- Reframing abuse to create an illusion of control or power (e.g. rationalising, minimising)
- Attempting to master the trauma
- Attempting to control other areas of life besides the trauma
- Seeking confirmation or evidence from others
- Rejecting power/authority [and intimacy and trust]
People who use ‘mature’ coping mechanisms are happier, enjoy better mental health, and more gratifying personal relationships (Mounier & Andujo, 2003). Even though the childhood coping strategies used by many adult survivors succeed in keeping them from feeling overwhelmed and/or help manage helplessness, powerlessness or lack of control, they have a cost. For example, the strategies to help manage helplessness and powerlessness can control the survivor (Morrow & Smith, 1995).
2. ADAPTIVE VERSUS MALADAPTIVE COPING STRATEGIES
The manner in which individuals react to or cope with stressful situations influences the long-term impact of those stressors, and differences in coping are important contributors to psychological adjustment (Min, Farkas, Minnes, & Singer, 2007).
The identification of adaptive and maladaptive coping strategies following traumatic events has been the subject of much scientific enquiry (Littleton, Horsey, John, & Nelson, 2007). Two primary conceptualisations of adaptive and maladaptive coping have emerged in the literature:
- a) problem-focused or emotion-focused
- b) approach-focused or avoidance-focused (Littleton et al., 2007).
Problem-focused or emotion-focused coping:
Problem-focused coping strategies are those that directly address the problem and include seeking information about the stressor, making a plan of action, and concentrating on the next step to manage or resolve the stressor (Littleton et al., 2007).
Emotion-focused strategies concentrate on managing the emotional distress associated with the stressor and include disengagement from emotions related to the stressor, seeking emotional support and venting emotions.
It is argued that problem-focused strategies are more adaptive in controllable situations; whereas emotion-focused strategies are more adaptive in uncontrollable situations (Littleton et al., 2007).
Approach versus avoidance coping:
Approach strategies focus on the stressor itself or one’s reaction to the stressor. Examples include: seeking emotional support, planning to resolve the stressor, and seeking information about the stressor (Littleton et al., 2007).
Avoidant coping refers to techniques which deny, minimise, and delay dealing with stressors. Avoidance strategies are focused on avoiding the stressor or one’s reaction to it; for example, withdrawing from others, denying the stressor exists, and disengaging from one’s thoughts and feelings regarding the stressor (Littleton et al., 2007). Avoidant coping strategies are typically ineffective for eliciting social support or engaging in problem solving activities (Min et al., 2007).
Approach strategies are generally regarded as more adaptive than avoidant coping strategies. Although avoidance strategies may reduce distress in the short term, they are regarded as maladaptive if an individual continues to rely on them (Littleton et al., 2007).
The concept of avoidant coping styles has been used to explain the relationship between childhood trauma and adult problems (Min et al., 2007). Studies have identified that avoidant coping is a good predictor of poor psychological health and PTSD (Futa et al., 2003; Min et al., 2007; Ullman, Filipas, Townsend & Starzynski, 2007) and is a particularly problematic approach to dealing with the aftermath of trauma (Krause, Kaltman, Goodman, & Dutton, 2008).
Research has demonstrated that an increase in daily stress is associated with a decline in health (discussed in Cromer & Sachs-Ericsson, 2006). Research shows that stress experienced by adult survivors of childhood trauma and abuse has a greater impact on their health than stress experienced by the general population (Cromer & Sachs-Ericsson, 2006). Furthermore, in the presence of current stressors, rates of health problems increased more for those who had been abused than for those who had not been. Specifically, the study showed that current stressors approximately double the negative impact of abuse on health, which translates into substantially higher rates of serious health problems in the population (Cromer & Sachs-Ericsson, 2006). The use of adaptive versus maladaptive coping strategies may, at least in part, explain this finding. Another explanation may relate to the alteration in the production of cortisol in some survivors of childhood abuse (Joyce et al., 2007).
COST TO THE COMMUNITY
A review of the consequences of child abuse indicates that costs can be broadly categorised under the headings: human cost of those abused, long-term human and social cost, cost of public intervention, and cost of community contributions (Kids First Foundation, 2003). The long term human and social cost include mental disability, increased medical service usage, chronic health problems, lost productivity, juvenile delinquency, adult criminality, homelessness, substance abuse and intergenerational transmission of abuse (Kids First Foundation, 2003).
Child sexual abuse has been found to be a key factor in the cause and continuation of youth homelessness with between 50-70% of young people within Supported Accommodation Assistance Programs having experienced childhood sexual assault (van Loon & Kralik, 2005b).
Consequently, it is not surprising that childhood abuse is associated with increased healthcare utilisation and costs. According to NSW Health (1998), survivors of child sexual abuse accounted for 34% of all presentations across the mental health sector in 1998. Survivors of child sexual abuse constitute the greatest number of women requesting services both from the NGO and mental health sectors (Henderson, 2006). In addition, research suggests that approximately 35% to 70% of female mental health patients self-report, if asked, a childhood history of abuse (Briere, 2004).
Walker et al. (1999) examined health care utilisation in the US and found that women who reported a history of child sexual abuse were more likely to visit hospital emergency facilities, had annual total health care costs significantly higher than those without abuse histories and that these differences were observed even after excluding the costs of mental health care.
In a National report published by the Kids First Foundation (2003) highlighting the cost of child abuse and neglect in Australia, it was estimated that the cost to Australian taxpayers was approximately $5 billion per annum. The long term human cost and cost of public intervention was estimated at three quarters of the annual cost, and the long term human and social cost at $2 billion per annum (Kids First Foundation, 2003).
In 2007, it is estimated that there were 130,237 children who were abused or neglected for the first time in Australia. This figure could be as high as 490,000 children. Based on these numbers, the projected cost of child abuse and neglect that will be incurred by the Australian community over the lifetime of children who were first abused or neglected in 2007 was $13.7 billion, but could be as high as $38.7 billion (Taylor et al., 2008).
A study by the United Kingdom National Commission of Inquiry into the Prevention of Abuse estimated that the cost of child protection services, as well as the additional mental health and correctional services associated with child abuse, was over one billion pounds per year in England and Wales (cited in Kids First Foundation, 2003). Similar figures also emerged from an American study, "Prevent Child Abuse" which
Conservatively claimed that US$94 billion was spent annually in response to child abuse (cited in Kids First Foundation, 2003).
PATHWAYS THROUGH WHICH ADULT HEALTH CAN BE COMPROMISED
We have all heard the saying “What doesn’t kill you makes you stronger” and “time heals all wounds”. These bits of common wisdom conjure a picture of traumatic experiences that, once overcome, result in greater levels of psychological, physical and emotional wellbeing. Although trials and tribulations can certainly build character, they can also create permanent biological, neurological and psychological compromise (Cozolino, 2002). The impact of traumatic events on infants and young children is often minimized in this way. It is ironic that during infancy and childhood, a time of the greatest vulnerability to the effects of trauma adults generally presume greater resilience (Perry, Pollard, Blakely, Baker, & Vigilante, 1995). The effects of early and severe trauma are widespread, devastating and difficult to treat (Cozolino, 2002; Giarratano, 2004a).
Childhood trauma can cause severe disturbances in the integration of sensory, emotional and cognitive information into a cohesive whole. This sets the stage for unfocused and irrelevant responses to subsequent stress (Cozolino, 2002; Streeck-Fischer & van der Kolk, 2000). For example, a lack of capacity for emotional self-regulation has been commonly observed in children who experience abuse and neglect (Streeck-Fischer & van der Kolk, 2000). Childhood trauma has a profound impact on the emotional, behavioural, cognitive, social and physical functioning of children (Perry et al., 1995). Among other impacts, a traumatised child may, over time, exhibit motor hyperactivity, anxiety, behavioural impulsivity, sleep problems, hypertension and a variety of neuro-endocrine abnormalities (Perry et al., 1995).
Similarly, adult survivors of childhood abuse have consistently identified impairments in adult physical and mental health in studies (Draper et al., 2007). Even though not everyone exhibits the same set of symptoms, or experiences the same intensity of problems, research shows that the long-term effects of child abuse are pervasive, across all areas of a survivor's world.
Although the association between childhood abuse and adult mental and physical health problems is well documented, less is known about the pathways through which health is compromised. An understanding of the effects of child abuse and neglect on a child’s physical (biological), cognitive, social, behavioural and emotional development helps make sense of their repercussions in adulthood. Pathways linking childhood abuse with adult health outcomes span emotional, behavioural, social, cognitive, and biological pathways.
Primary attachment to help modulate stress
There is evidence that caring and secure environments help to moderate the negative impact that stress places on the developing brain (Gunnar, 1998). Safety and bonding are crucial factors in the early construction of the brain. Childhood trauma can compromise core neural networks (Cozolino, 2002).
Normal childhood play and exploratory activity requires the presence of a familiar attachment figure to help modulate the child’s physiological arousal by providing a balance between soothing and stimulation (Streeck-Fischer & van der Kolk, 2000). Children feel secure when the caregiver provides consistent, warm and sensitive care (Davila & Levy, 2006). In secure environments, stressed children who seek and receive comfort from the primary caregiver, when comforted, return to their exploratory activity away from the parent (p. 989). The response of the caregiver not only protects the child from the effects of stressful situations by providing soothing when appropriate, but also enables the child to develop the biological framework for dealing with future stress (Schore, 1994; cited in Streeck-Fischer & van der Kolk, 2000). The acquisition of controllable stress reactions seems to result in central nervous system reactions that facilitate the capacity to deal with subsequent stresses.
In the absence of a secure base, children find they cannot rely on the primary caregiver for comfort and may become incapable of calming themselves down when threatened. In addition, if children are exposed to unmanageable stress and the caregiver does not help modulate the child’s arousal (as in situations of family violence) the child will be unable to organise his/her experiences in a coherent fashion (Streeck-Fischer & van der Kolk, 2000). If the child cannot regulate his/her emotional states, or rely on others to help: he/she will respond with fight or flight reactions. Cognitive understanding of events helps modulate emotions and enables the formulation of a flexible response. Both cognition and emotions are important. Children who are denied parental care or comfort for long periods of time, can suffer extreme mental and emotional deficits (Van Der Horst, LeRoy, & Van Der Veer, 2008).
Our first intimate or loving relationship is with our primary caregiver and this informs our expectations and patterns of behaviour (Harlow, 1958). For example, Bowlby (1969; 1973; 1980; 1988) identified a strong relationship between the pattern of attachment in young children and the patterns of their intimate relationships in later life. The negative core schema adopted by a survivor as a result of that first attachment fundamentally affects that survivor’s capacity to establish and sustain significant attachments throughout life. Survivors often experience conflictual relationships and chaotic lifestyles, frequently report difficulties forming adult intimate attachments and display behaviours that threaten and disrupt close relationships (Collins & Read, 1990; cited in Henderson, 2006).
Attachment theory, a theory of personality development emanating from John Bowlby's work (1988), can be used to explain the diverse array of negative outcomes in adult survivors of childhood abuse. Attachment theory suggests that early childhood relationships are internalised and inform an internal working model of the self, others and any relationships. The internal attachment model developed in childhood influences the patterns of relationship formation and attachment styles used in adult life. Difficulties associated with abuse-related attachment may be mirrored in relationships throughout a survivor's life. “Abusive acts thereby serve as an etiologic reservoir for the development of later psychological disorder” (Briere, 2002). Bowlby (1969, 1973, 1980, 1988) described four different patterns of attachment which determine children’s reactions in the presence or absence of their mother (or primary caregiver): secure attachments, ambivalent attachments, avoidant attachments and disorganised attachments.
- Secure attachments: ‘Securely attached’ children develop inner working models that see others as positively available and themselves as lovable, valued and socially effective (Bowlby1988). Overall, adults with secure attachments have effective strategies for regulating affect (Alexander & Anderson, 1994).
- Ambivalent attachments: ‘Ambivalent’ children experience parenting that is inconsistent, unreliable and emotionally neglectful. Persistent experiences of both emotional and physical neglect may lead children to suffer psychological distress resulting in feelings such as abandonment and rejection. The ambivalent child clings to the parent and exaggerates affect in order to take advantage of the intermittent responsiveness of their inconsistent parent. As an adult, the ‘ambivalent child’ may be described as clinging, jealous, obsessive, dependent, self-sacrificing, and describe love as a series of emotional highs and lows (Alexander & Anderson, 1994). ‘Ambivalent’ adults may be especially sensitive to the possibility of abandonment, rejection or isolation (Bowlby1988).
- Avoidant attachments: ‘Avoidant’ children experience parenting that is hostile, rejecting and controlling. They experience little warmth or love and their emotional needs remain largely unmet (Bowlby1988). Parents of the avoidant child are not necessarily consistently rejecting; however, their coldness and lack of responsiveness are sure to emerge at the point when the child needed help. The parent of the avoidant child may respond positively to the child’s autonomous behaviours but be misattuned to the child’s request for nurturance (Alexander & Anderson, 1994). Therefore, the learned response of the avoidant child is to hold back when feeling needy so as not to elicit even more rejection from the parent. This reluctance to express negative affect becomes internalised and may take form of compulsive self-reliance (Bowlby, 1969). As an adult the ‘avoidant child’ may be uncomfortable with intimacy, not confident about others’ availability, highly self-reliant, seen as hostile to others, easily frustrated with partners, and overtly denying of problems while exhibiting covert symptoms of anxiety, distress, and dysfunction (Alexander & Anderson, 1994).
- Disorganised attachments: The parent of the disorganised child tends to be frightening and/or frightened in his/her interactions with the child. Consequently, the disorganised child is in the untenable position of having to approach the very caretaker who is the source of the child’s anxiety and fearfulness (Alexander & Anderson, 1994). Unable to regulate their affect, these children adopt coping strategies such as dissociation when interacting with the parent. A study by Hertsgaard, Gunnar, Erickson, & Nachmias (1995) found that infants who exhibit disorganised attachment patterns have higher baseline cortisol levels. As adults ‘disorganised children’ they may see themselves as truly bad, responsible for their trauma and inherently flawed. They may experience significant distress, depression, and poor social adjustment (Alexander & Anderson, 1994).
Early patterns of attachment set the stage for how children process information and have powerful effects across the lifespan. Secure infants usually grow up being able to rely on both their emotions and thoughts to help them determine reactions to any given situation. Children in abusive environments may learn to either ignore what they feel (emotions) or what they perceive (cognition) (Streeck-Fischer & van der Kolk, 2000). For example, avoidant children ignore their distress and deal with their needs by relying upon the logic of what they can observe. Being able to inhibit their distress protects them from further harm. Ambivalent children may tend to grow up relying on what they are feeling, without much thought about the consequences of their actions. Confused about what they perceive, they tune into their feelings, at the expense of being able to think about the meaning of their experiences (Streeck-Fischer & van der Kolk, 2000).
Behavioural pathways link childhood abuse and adult health outcomes through health-related behaviours, such as smoking, substance abuse, overeating, high-risk sexual behaviour, and suicidal behaviour (Draper et al., 2007). In essence, survivors of child abuse are more likely to engage in high-risk behaviours that are deleterious to health (Draper et al., 2007).
The high risk behaviours (alcohol abuse etc.) observed in adult survivors can be viewed as ‘coping strategies’, initially adopted in childhood, to manage rejection, betrayal and abuse. The trauma of child abuse is said to stall thought development and behavioural responses. This can potentially lock survivors into the avoidant coping strategies they used during their childhood (such as detaching, denying, forgetting, dissociating, fantasising and withdrawing). The tendency to dissociate remains with the child as he/she grows into adulthood and impairs the development of adaptive coping mechanisms (Briere, 2002). As explained by Perry et al. (1995) if the threat is ongoing, as is often the case in child abuse situations, responses to threat become ‘traits’. As such, some of the impacts of childhood abuse observed in adult survivors can be the result of the coping strategies used by children in abusive environments (Henderson, 2006). The extreme coping strategies required to manage the extremes of traumatic stress can create serious symptoms (adaptations). The symptoms of psychological trauma include components of every diagnostic category as well as disruptions in identity, attachments, relationships, meaning and spirituality (Saakvinte, Gamble, Pearlman, & Tabor, 2000).
As explained by the women participants in a study by Van Loon and Kralik (2005a):
We spent our childhood maintaining a shroud of ‘silence and secrecy’ around our perverse experiences of child abuse. We coped by ‘suppressing memories’, ‘learning to forget’, ‘disengaging’, disassociating’, ‘isolating ourselves emotionally and relationally’, ‘trying to please everyone’, ‘trying to adapt’ and accommodate our ‘weird’ situation’, because there was ‘no escape anyway’. This allowed us to survive our childhood. But as we became teenagers we came ‘unstuck’. We knew we ‘didn’t fit in’. So we ‘numbed our rotten feelings’ by using alcohol, drugs and/or gambling.
Cognitive pathways include the beliefs and attitudes one adopts that shape daily life.
Some of the long-term impacts of child abuse may be grounded in the rejection and betrayal the child experienced, and their impact on cognitive patterns. As children, survivors of child abuse have often been betrayed, manipulated and silenced by the adult/s they should have been able to trust.
Most cognitive theories of development acknowledge that we organise the world according to emotion (Ayoub et al., 2006). In particular, we tend to have a natural bias towards the positive, especially when evaluating ourselves (Ayoub et al, 2006, p. 4). Children who experience severe and/or ongoing maltreatment will tend to develop a negative bias especially towards themselves (Ayoub et al, 2006). There is a tendency for children experiencing child abuse to attribute blame to themselves and to internalize abusive behaviours (Quas, Goodman, & Jones, 2003). These tendencies become cognitive patterns that can continue long into adulthood, and contribute to delays in the development of self-esteem and a healthy identity (van Loon & Kralik, 2005a).
Cognitive pathways are clearly intertwined with biological pathways. Children who are abused go immediately from (fearful) stimulus to fight/flight responses without learning from the experience because they can’t grasp what is happening (Streeck-Fischer & van der Kolk, 2000). Adult survivors’ responses to hostility or silence can often be misinterpreted as responses to current events rather than the conditioned reaction to reminders of the past they embody. Adult survivors tend to experience current stressors with an emotional intensity that belongs to the past, and has little value in the present (Streeck-Fischer & van der Kolk, 2000).
Social pathways link childhood abuse and its negative health outcomes through difficulties in establishing intimate relationships. The association between dysfunctional relationships and adverse mental and physical health outcomes has been frequently reported (Draper et al., 2007). Traumatic abuse in childhood can lead to chronic, negative expectations and perceptions around safety, trust, esteem, intimacy and control which are readily activated by interpersonal interactions in the present environment (Henderson, 2006).
Children exposed to environmental extremes in abusive situations and lacking an adult to provide continuity, can have a problem understanding themselves or others (Streeck-Fischer & van der Kolk, 2000). As they have no clear appreciation of who they or others are, such children do not know how to enlist other people as allies; people are perceived as sources of terror or gratification, but rarely fellow human beings with their own sets of needs and desires (Streeck-Fischer & van der Kolk, 2000). Unable to regulate their feelings, abused children are prone to scare other children (and in time adults) away and hence lack reliable playmates (Streeck-Fischer & van der Kolk, 2000). Parental child abuse not only traumatises children, but also deprives them of healing interactions (Cozolino, 2002).
Two-thirds of the long-term negative mental health effects of child abuse are related to poor educational, work choices and deficiencies in intimate relationships, with poor intimate relationships and career choices being amongst the most influential. This suggests that the social development pathway is significantly impacted by childhood abuse causing negative emotional or psychological outcomes in adulthood (Schilling, Aseltine, & Gore, 2007). A study by Schilling, Aseltine & Gore (2007) concluded that developing strong social supports was an important factor in ameliorating the effects of depression in a group of adult adolescents who had experienced severe abuse.
Neural development and social interactions are inextricably intertwined. As Tucker (1999, p. 199) says “for the human brain, the most important information for successful development is conveyed by the social rather than the physical environment” (cited in Streeck-Fischer & van der Kolk, 2000). For example, a study by Valentino, Cicchetti, Toth, & Rogosch (2006) found that mothers in abusive families were less available to play and interact socially with their infants even when they were 12 months of age. As a consequence, infants from abusive families demonstrated more imitative and less independent play than infants from non-abusing families.
Vulnerability to hyperarousal makes it difficult to tolerate uncertainty (Streeck-Fischer & van der Kolk, 2000). Avoiding novelty also leads to avoiding social contact. Hence, abused children miss out on the normal transmission of social skills (Streeck-Fischer & van der Kolk, 2000).
Seventy percent of our genetic structure is added after birth (Schore, 1994; cited in Cozolino, 2002). While the fundamental neuro-anatomical structure of the brain is genetically determined, the templates determining the categorisation and interpretation of experience within the limbic system and frontal lobes gradually develop as a child grows. Experience shapes the structure in which the brain is being organised (Streeck-Fischer & van der Kolk, 2000). Developmental experiences determine the organizational and functional status of the mature brain (Perry et al., 1995). A child’s interaction with the outside environment causes connections to form between brain cells (McLean Hospital, 2000). Because the developing brain organizes and internalizes new information in a use-dependent fashion, the more a child is in a state of hyper-arousal or dissociation, the more likely he/she is to have neuropsychiatric symptoms following trauma. The acute adaptive state can persist and cause maladaptive traits (Perry et al., 1995). In other words, continuing threat impacts the child’s developing brain and the responses to threat become ‘personality traits’ (Perry et al., 1995).
Impact on the physiology of the brain
Studies with survivors of childhood abuse have found:
- Impact on the cortex and limbic system
Research shows that children and adults with histories of child abuse can respond to minor triggers with a range of catastrophic reactions. This is because traumatised children (and adult survivors) become increasingly responsive to relatively minor stimuli as a result of decreased frontal lobe functioning (learning and problem solving) and increased limbic system (amygdala) sensitivity (impulsiveness) (Streeck-Fischer & van der Kolk, 2000).
- Decreased cortex activity
The cortex or the more rational, outer-layer of the brain is the seat of our thinking capacity. The cool, rational cortex is in constant communication with the amygdala and the hippocampus (the limbic system). The frontal lobes are situated in the cortex and are responsible for learning and problem solving. The capacity to learn from experience requires events to be registered in the prefrontal cortex, compared with other experiences and evaluated for an appropriate response (Streeck-Fischer & van der Kolk, 2000).
When children feel they are being threatened, the fast tracts of the limbic system are likely be to activated before the slower prefrontal cortex has a chance to evaluate the stimulus (Streeck-Fischer & van der Kolk, 2000). Only a state of non hyper-arousal allows the activation of the prefrontal cortex needed for learning and problem solving.
- Increased limbic system sensitivity
The limbic system is a network of brain cells sometimes called ‘the emotional brain’. It controls many of the most fundamental emotions and drives pertinent for survival (McLean Hospital, 2000). The limbic system is the area in the brain that initiates the fight, flight or freeze responses in the face of threat. The amygdala and the hippocampus are part of the limbic system. A study by Teicher et al. (1993) found a 38% increased rate of limbic abnormalities (‘emotional brain’) following physical abuse, 49% after sexual abuse, and 113% following abuse of more than one type combined (cited in Streeck-Fischer & van der Kolk, 2000).
The amygdala processes emotions before the cortex gets the message that something has happened. For example, the sound of a loved one’s voice is communicated to the amygdala, and the amygdala generates an emotional response to that information (for example, pleasure) by releasing hormones. When someone is threatened, the amygdala perceives danger and sets in motion a series of hormone releases that lead to the defensive responses of fight, flight or freeze. As the amygdala is immune to the effects of stress hormones it may continue to sound an alarm inappropriately, as is the core of post traumatic stress disorder (PTSD) (Rothschild, 2004).
The amygdala’s role in the encoding, storage and retrieval of emotionally-arousing material (and corresponding hormonal changes) primes animals to remember emotionally-charged or threatening events better than everyday events (Howe, Cicchetti and Toth, 2006).
- Decreased hippocampal volume
The hippocampus helps to process information and lends time and spatial context to memories and events. The hippocampus assists the transfer of initial information to the cortex which works to make sense of the information. However the hippocampus is vulnerable to stress hormones, in particular the hormones released by the amygdala’s alarm. When these hormones reach a high level, they suppress the activity of the hippocampus and it loses its ability to function. Information that would make it possible to differentiate between a real and an imagined threat never reaches the cortex and a rational evaluation of the information isn’t possible (Rothschild, 2004).
If a particular stimulus is misinterpreted as a threat, this leads to immediate fight/flight/freeze responses (to non-threatening stimuli). This causes this system to respond to minor irritations in a totalistic manner (Streeck-Fischer & van der Kolk, 2000).
Research shows that environments of extreme stress lead to increased cortisol levels (Murray-Close, Han, Cicchetti, Crick, & Rogosch, 2008) which can lead to decreased hippocampal volume. Decreased hippocampal volume has been associated with poorer declarative memory which places adults at greater risk of developing PTSD-like symptoms, and is closely correlated with experiences of depression and physical inflammations (Danese, Pariante, Caspi, Taylor & Poulton, 2006).
- Underdevelopment of left brain
A study by McLean Hospital (2000) found that children with histories of abuse were twice as likely as non-abused children to have abnormal EEGs. Research shows evidence of deficient development of the left brain hemisphere in abused patients (which controls language), suggesting that the right hemisphere may be more active than in healthy individuals (McLean Hospital, 2000).
- A smaller corpus callosum
The corpus callosum is a major information pathway connecting the two hemispheres of the brain (McLean Hospital, 2000). A number of studies have found that the corpus callosum is smaller in abused children than in healthy children (De Bellis et al., 1999; McLean Hospital, 2000; Teicher, Ito, Glod, & Andersen, 1997). Furthermore, McLean Hospital (2000) found that abused patients shifted the degree of activity between the two hemispheres to a much greater extent than normal. They theorised that a smaller corpus callosum leads to less integration of the hemispheres. This can lead to dramatic shifts in mood or personality.
- Neuro-endocrine alterations
Brain development is affected by stress early in development. Extensive research has been carried about the neuro-biology of stress. The link between a history of childhood abuse and neglect and neuro-endocrine impacts is well established. Research tells us that the bodies of children who are being abused react and adapt to the unpredictable dangerous environments to which they are exposed. Stress can set off a ripple of hormonal changes that permanently wire a child’s brain to cope with a malevolent world (Teicher, 2002). Through this chain of events, violence and abuse pass from generation to generation (Teicher, 2002).
The neuro-endocrine system refers to the system of interaction between our brain/ nervous system and the hormones in our bodies. This system helps regulate our moods, our stress response, our immune system, and our digestion, among other things. Any disruption to the neuro-endocrine system affects a range of basic psychological and physiological functions.
Research suggests that many of the long-term impacts of child abuse experienced by adult survivors result from the chronic neuro-endocrine dysregulation caused by prolonged exposure to abuse and violence (Kendall-Tackett, 2001). Activity of the hypothalamic-pituitary-adrenocortical (HPA) axis has been identified as mediating the effects of adversity on the developing brain. The HPA axis consists of the hypothalamus and the pituitary gland in the brain and the adrenal glands at the top of the kidneys. The HPA Axis is a major part of the neuroendocrine system that controls reactions to stress and regulates body processes, including digestion, the immune system, mood and emotions, sexuality, and energy storage and expenditure.
- Impact on stress hormones (including impact on cortisol production)
Even in utero foetuses experience stress (Cozolino, 2002). Tests have found that foetuses express a biological response indicative of a stress response well before birth (Gunnar, 1998). The two hormones that are associated with increased arousal (as found in animal studies) are cortisol and adrenocorticotropic hormone.
The nervous systems of children who are abused run on a constant high because they are constantly anticipating further danger. Their bodies are flooded with fight-or-flight hormones (Cozolino, 2002). A study by Linares et al. (2008) shows a neuro-endocrine alteration in cortisol production in children with histories of abuse and neglect. This state of chronic “hyper-arousal” persists for many survivors throughout their adult years as well. Even when the abuse and violence have ceased and the environment is ‘safe’, many adult trauma survivors still perceive the threat to be present; their fear is maintained and becomes pathological (Giarratano, 2004b). A study by Joyce et al. (2007) found that experiences of childhood abuse were associated with high cortisol levels in depressed adult survivors.
A number of studies have identified alterations in cortisol production in both children and adults who experienced childhood abuse (Carpenter et al., 2007; Joyce et al., 2007; Linares et al., 2008; McLean Hospital, 2000). Alteration in cortisol levels, either an increase or decrease, can cause a number of long-term physical and psychological health concerns.
- Impact on thyroid production
Studies conducted by McLean Hospital (2000) have found that neglect can also decrease production of thyroid hormone. This can lead to a number of health concerns as the thyroid gland secretes hormones which modulate metabolism.
Trauma is biologically encoded in the brain in a variety of ways. Changes in structures like the hippocampus, and the coordination and integration of neural network functioning have been identified. These changes are reflected in the victim’s physiological, psychological and interpersonal experiences (Cozolino, 2002). Deficits in psychological and interpersonal functioning then create additional stress which further compromise neurobiological structures. In this way, adaptation to trauma, especially early in life, becomes a “state of mind, brain, and body” around which subsequent experience organises (Cozolino, 2002).
Many models, therapeutic approaches and techniques are used by health professionals who work with adult survivors of childhood trauma and abuse. Clients present for treatment at different stages of recovery, with varying symptoms, medical histories, coping strategies and levels of functionality. Many approaches are integrative or eclectic and demonstrate responses to individual client needs during the recovery process (Henderson, 2006).
The medical model is the dominant model utilised by clinicians working in mental health settings, particularly for depression and anxiety disorders (Henderson, 2006). It holds a 'disease' perspective and adult survivor clients are often categorised according to their symptoms, which are many and varied, without attention to the meaning, function and causes of these symptoms.
The medical model focuses on symptoms and diagnoses while viewing behaviour outside of a context. Diagnoses are drawn from the behavioural elements of a disorder, without consideration as to the aetiology of these behaviours (e.g. to cope with the trauma). Diagnosis highlights what is wrong with a person and pathologises while ignoring adaptations, coping mechanisms, and elements of resilience (Saakvitne et al., 2000). The focus is 'there is something wrong with this person' rather than 'something wrong happened to this person'. The medical discourses that categorise abuse experiences as pathology, and the survivor or 'victim' as damaged, are disabling; and render survivors powerless in their capacity to reclaim and reshape their identity after such toxic human interactions (van Loon & Kralik, 2005a).
Although most survivors report symptoms consistent with PTSD or complex PTSD, the diagnosis more typically assigned to survivors is of a personality disorder (see Herman, 1992). A personality disorder is a pervasive and enduring disruption of the ability of a person to function normally (Millon, 1991; cited in Walker, 1994). However, the question of what is 'normal' within the mental health context is the subject of much debate.
The diagnosis of borderline personality disorder (BPD) is not unusual for women with symptoms resulting from childhood or adult violence or trauma (see Sansone, Sansone, & Wiederman, 1995). A diagnosis of BPD for survivors has traditionally implied likely failure to recover (Candib, 1995). Candib (1995) argues that the label of BPD is stigmatising and ignores the link between abuse, trauma and a survivor's response. She argues that this diagnosis may result not only in an inappropriate or fragmented approach to treatment, but to broader ramifications such as losing custody of children or inability to secure health insurance.
Personality disorder diagnoses can result in inadequate and even harmful treatment for abuse survivors. Survivors attest that the symptom-focused, diagnosis-based, therapist-as-authority figure framework that guides many health providers often harms adult survivors (Harper et al., 2007; O'Brien, Henderson, & Bateman, 2007). The power structure of the medical model recreates a situation of dependence associated with danger, pain and betrayal for survivors of childhood abuse (Linehan, 1993a).
A study by Harper et al. (2007) found that the quality of survivors' relationships with their therapists was negatively impacted when participants perceived that their therapists viewed them as 'mentally ill', rather than as suffering the effects of repeated traumatic experiences (Harper et al., 2007). The fear participants held that they would be perceived as needing psychiatric hospitalization inhibited their ability to share their thoughts and feelings (Harper et al., 2007).
A trauma-based approach "serves to normalise symptoms and behaviours that have traditionally been pathologised and viewed as examples of personal and social deviance" (Bloom, 1997, p. 70). It views the individual as having been harmed by something or, more often, some person or persons, "thus connecting the personal and the socio-political environments" (Bloom, 1997, p. 71). Instead of asking clients "What is wrong with you?" the trauma-based approach asks: "What happened to you?" This framework expects individuals to learn about the nature of their injuries and to take responsibility in their own recovery (Bloom, 2000).
THE SELF-TRAUMA MODEL
Within the self-trauma model Briere has integrated facets of trauma theory, Cognitive Behaviour Therapy (CBT), behavioural therapy and self-psychology for working with adult survivors of child abuse (Briere, 2002). Although this perspective is cognitive behavioural, it is also an attempt to rework psychodynamic theory to encompass empirically based principles as they relate to child abuse survivors (Briere, 2002).
Briere (2002) suggests that child abuse and neglect often disrupt child development and produce future symptomatology in several ways:
- by altering early childhood attachment dynamics;
- through the effects of early posttraumatic stress on subsequent development;
- by motivating the development of primitive coping strategies; and
- by distorting the child's cognitive understanding of self, others and the future.
The self-trauma model calls upon cognitive behavioural and relational research and theory to address the many cognitive, emotional, behavioural and interpersonal effects of child abuse. The model stresses the client's self capacities such as skills of affect tolerance and affect modulation (Briere, 2004). Many untreated survivors of childhood abuse spend considerable time and energy attempting to counter trauma- related distress with avoidance mechanisms such as dissociation, externalisation or substance abuse. Such avoidance (although reinforced by immediate effectiveness in reduction of dysphoria) may prevent adequate processing of traumatic material, thereby leaving post traumatic symptoms relatively undiminished (Briere, 2004).
A primary goal of self-trauma therapy is to avoid overwhelming the client (either by exposing them to unacceptable levels of post traumatic distress or by inappropriate discouragement of critical avoidance-activities). At the same time the therapist must facilitate exposure to traumatic material so it can be desensitised and integrated (Briere, 2004). The therapist must provide a safe therapeutic environment to counter-condition anxiety associated with disclosure (Briere, 2004). Effective therapeutic responses occur on a continuum with interventions at one end devoted to greater awareness of potentially threatening, but therapeutically important material (exposure), through to interventions that support and solidify previous progress (consolidation). Consolidation is concerned with safety and involves activities that reduce arousal and ground the client in the here and now (Briere, 2004). The decision at any given moment to explore and process, or to consolidate, reflects the therapist's assessment of the direction in which the client's balance is tilting (Briere, 2004). In the absence of sufficient affect regulation skills, even small amounts of distress may be experienced as overwhelming and thereby motivate avoidance. Some clients may require extensive self-work before any significant trauma-focused interventions can be used (Briere, 2004).
CONSTRUCTIVIST SELF DEVELOPMENT THEORY (CSDT)
A trauma model of working with adult survivors of childhood abuse developed by Saakvitne et al. (2000) is called Constructivist Self Development Theory (CSDT). This model, based on a trauma framework, assumes that just as people can harm each other deeply, so can they help each other profoundly. CSDT assumes that childhood abuse interrupts the normal development of a person's ability to identify and regulate their feelings. This is similar to other trauma frameworks that emphasise the importance of learning 'feeling skills' (Briere, 2004; Linehan, 1993a). CSDT focuses on hope, connection, collaboration, respect and empowerment.
Saakvitne et al. (2000) stress that when a child depends on an adult for nurture, safety, love and connection, he or she should not be taking a risk. Once betrayed, future attachments and interpersonal connections require risking disappointment and perhaps shame, neglect and/or abuse. In adulthood, survivors of childhood abuse often find it risky to make connections between their past and present, their thoughts and feelings. Most survivors need the support of interpersonal connections to restore meaning and wholeness in their lives (Saakvitne et al., 2000).
In essence, CSDT:
- Emphasises the healing power of the relationship between the health professional and the survivor
- Views symptoms as adaptations
- Posits that crises can best be managed and eventually reduced through the development of 'feeling skills'
- Views the person of the therapist as an essential part of the healing process
- Expects the work to have an impact on the therapist that parallels the impact of trauma on the survivor
SOMATIC TRAUMA THERAPY
Somatic Trauma Therapy, developed by Babette Rothschild, is an integrated treatment model that draws from the most relevant theory and suitable techniques for understanding and treating trauma and PTSD. It is an eclectic approach in which the practitioner continually evaluates the most effective interventions for trauma related problems (Rothschild, 2003). Somatic Trauma Therapy is an integrated system of psychotherapy and body-psychotherapy that continues to evolve as new theory and techniques emerge in the field. It addresses all aspects of the trauma's impact (on thinking, emotions and bodily sensations) bringing them into sync, and relegating trauma to its rightful place in the past (Rothschild, 2003).
The concept proposes that the 'The Body Remembers' and becomes a resource in the treatment of trauma. By understanding how the brain and body process, recall and internally perpetuate traumatic events once the trauma is over, the client learns how to regulate affect and pain (Rothschild, 2003).
The model 'Traumagenic Dynamics' formulated by Finkelhor & Browne (1985) explains the traumatisation that occurs in child sexual abuse survivors. The model is based on empirical and clinical reports in the literature rather than clinical work. It proposes four traumagenic dynamics to explain the impacts of childhood sexual abuse:
- traumatic sexualisation, which explains how sexuality is shaped, often in an inappropriate and dysfunctional manner, by several processes
- stigmatisation, which focuses on the negative messages transmitted in the abuse experience
- betrayal, which occurs when the victim discovers that a person he/she trusts and depends upon, wishes to and/or causes him/her harm
- powerlessness, which consists of repeated overruling and frustration of desires and wishes, along with a reduced sense of productivity; and the threat of injury and annihilation leading to disempowerment.
Survivor therapy is a treatment approach developed by Lenore A. Walker designed to help survivors of man-made traumas. It is based on the treatment approaches of both feminist therapy theory and trauma theory, integrating the consistent philosophies and borrowing techniques from each. The treatment approach of survivor therapy has been used successfully for the past decade by clinicians working with women and children who are victims or survivors of men's violence. Men who have experienced violence have also been helped by this approach, although the clinical group is a small one on which to make such evaluations. On the basis of an analysis of power, survivor therapy treats victims of violence by focusing on their strengths, despite their injuries. It takes into account the gender based impact of trauma within the woman's socio-political, cultural, and economic context, emphasising respect and empathy for all women who have been abused. Survivor therapy explores the coping strategies adopted by victims and builds on their strengths while exploring new ways of coping and so enabling victims to become survivors (Walker, 1994).
POST-TRAUMATIC STRESS MODEL: PTSD AND COMPLEX PTSD
The relationship between child abuse and adult psychopathology was initially conceptualised in terms of PTSD, and focused on trauma-induced symptoms, particularly dissociative disorders, amnesias and even multiple personality (Mullen, King, & Tonge, 2000). This theory proposed that the stress-induced symptoms created during the abuse produce a post-abuse syndrome in adult life. PSTD theory postulates that traumatic experiences profoundly impact the ways in which people deal with their emotions and their environments (Van der Kolk, McFarlane, & Weisaeth, 1996).
PTSD includes a set of 3 symptom groups:
- Intrusive recollections of the trauma: People with PTSD repeatedly re-live the trauma through flashbacks, hallucinations and nightmares. Certain triggers such as the anniversary date of the event can cause heightened distress.
- Avoidance: The person may avoid people, places, thoughts or situations that remind him or her of the trauma. This can lead to feelings of detachment and isolation from family and friends, as well as a loss of interest in previously enjoyed activities.
- Increased arousal: Symptoms include excessive emotions; problems relating to others, including feeling or showing affection; difficulty falling or staying asleep; irritability; outbursts of anger; difficulty concentrating; and being 'jumpy' or easily startled. Physical symptoms of hyper-arousal may also be a feature, such as increased blood pressure and heart rate, rapid breathing, increased muscle tension, nausea and diarrhoea.
Research has consistently documented the relationship between PTSD and child abuse (Lindberg & Distad, 1985; Spila et al., 2008).
A study by Lindberg & Distad (1985) assessed the experiences of 17 women who had experienced childhood or adolescent incest and found that they appeared to fit the features of chronic and/or delayed PTSD. All the women in this study regarded their incest experience as the most damaging event/s of their lives, and had manifested, in adulthood, such symptoms as intrusive imagery of the incest, feelings of detachment or constricted affect, sleep disturbance, guilt, and intensification of symptoms when exposed to events resembling the incest trauma. Treatment included establishment of trust, expression of feelings, guilt reduction through an understanding of family dynamics and acquisition of new, adaptive behaviours.
Data from a large-scale study in the USA comparing the effects of different types of traumatic events suggests that the experience of child sexual abuse and sexual abuse (male and female) may be more likely to lead to PTSD than other types of traumatic events. This percentage at 54% was significantly higher than the 38.8% diagnosed in men who had experienced combat (Kessler, Sonnega, Bromet, Hughes & Nelson, 1995).
The PTSD model can inform a treatment plan by understanding the psychological damage experienced by the child. A study by Harper et al. (2007) identified that survivors of childhood abuse find it helpful when health professionals understand and recognise PTSD. Harper et al. (2007) note, however, that the practice guidelines for the treatment of PTSD have been primarily developed based on studies with survivors of trauma experienced in adulthood only. Therefore, a useful expansion of the model may be a more detailed evaluation of the impact on the developing cognitive and social skills of the child, particularly in relationships with peers.
Childhood abuse is increasingly being recognised as producing complex post traumatic syndromes (Cole & Putnam, 1992). Complex PTSD (as identified by Herman, 1992), also known as "disorder of extreme stress, not otherwise specified" (DESNOS), is thought to arise from severe, prolonged and repeated trauma, almost always of an interpersonal nature, such as child abuse (Briere & Scott, 2006). The relational and identity disturbance subsumed under Complex PTSD includes: the tendency to be involved in chaotic and frequently maladaptive relationships, to have difficulties negotiating interpersonal boundaries, and reduced awareness of one's entitlements and needs in the presence of others. This is often attributed to a history of inadequate parent-child attachment (Briere & Scott, 2006).
The category of Complex PTSD was considered during the preparation of the DSM-IV but not ultimately included. Complex PTSD measures the more enduring characteristics demonstrated by victims of repeated trauma, many of whom are incest survivors (see Herman, 1992). Many therapists who treat survivors of childhood abuse believe that such a diagnostic category would permit greater access to appropriate treatment than focusing on the situational trauma and its subsequent sequelae (Herman, 1992).
Medication can minimise the anxiety, depression and insomnia often experienced by survivors of child abuse. It may help relieve the distress and emotional numbness caused by traumatic memories. Several types of antidepressants have proved beneficial in most (but not all) clinical trials, and other classes of medication have shown promise. No single medication has emerged as a definitive treatment for PTSD (Henderson, 2006). Medication is useful for symptom relief, enabling survivor participation in psychotherapy (Briere & Scott, 2006).
Cognitive Behavioural Therapy (CBT)
There are various treatments that fall under the umbrella of the cognitive behavioural approach, but the underlying emphasis is upon helping the PTSD patient to modify their distorted cognitions (Giarratano, 2004a). Cognitive restructuring and other forms of reframing help clients gain cognitive control and the ability to understand previously confusing information. CBT works with cognitions to change emotions, thoughts and behaviours. In a safe, controlled context, the client is encouraged to face and gain control of the overwhelming fear and distress that they experienced during the trauma. Cognitive therapy aims to help the PTSD sufferer understand and change how he or she thinks about the trauma and its aftermath. The goal is to understand how certain thoughts about the trauma cause stress and make symptoms worse. CBT for trauma includes: learning how to cope with anxiety and negative thoughts, managing anger, preparing for stress reactions, handling future trauma symptoms, addressing urges to 'self-soothe' with alcohol or drugs and communicating and relating effectively with people (National Centre for PTSD, 2008).
The CBT model when used with survivors of child abuse usually focuses on the 'here and now' rather than revisiting the trauma itself (Henderson, 2006).
The aim of exposure therapy is to reduce the fear surrounding memories. It is based on the idea that people learn to fear thoughts, feelings, and situations that remind them of a past traumatic event (Giarratano, 2004a). Exposure therapy argues that by talking about a trauma repeatedly with a therapist, the survivor will develop control over his or her thoughts and feelings about the trauma. The initial focus may be on less distressing memories before talking about more traumatic ones. This is called 'systematic desensitisation', and is used to reduce high levels of anxiety and phobic responses (National Centre for PTSD, 2008).
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is a treatment that facilitates the accessing and processing of traumatic material. It involves elements of exposure therapy and CBT combined with techniques such as rapid eye movements, hand taps, sounds. During EMDR the client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus. Therapist directed lateral eye movements are the most commonly used external stimulus but a variety of other stimuli including hand-tapping and audio stimulation are often used (Shapiro, 1991, cited in EMDR Institute). The aim of EMDR treatment is to relieve distress, reform negative beliefs, and reduce physiological arousal (EMDR Institute).
Eye movement therapy (EMT) was initially designed for trauma clients whose trauma is remembered subsequently on an affective level (sensory memory), rather than on a cognitive level (full conscious memory). It was viewed as useful for those who cannot easily verbalize what happened to them but who know from their affect that they were subjected to frightening and abusive acts (Walker, 1994). Based on evidence that suggests that trauma is stored in the unconscious and that all information is encoded in neural pathways, eye movement therapy argues that it is necessary to revisit these pathways by recalling the traumatic memories to erase the neural pathways (Walker, 1994).
Whilst the theory and research are still evolving for this treatment and controversy abounds, there is some evidence that the therapeutic element unique to EMDR enables clients to reduce trauma symptoms to such an extent that they can ultimately think about the events with almost no emotion (Henderson, 2006).
Experts are still learning how EMDR works. Studies have shown that it may help reduce PTSD symptoms but research also suggests that the eye movements are not a necessary part of the treatment (National Centre for PTSD, 2008).
Trauma Informed Care and Practice is a strengths-based framework grounded in an understanding of and responsiveness to the impact of trauma, that emphasises physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.
Blue Knot Foundation delivers trauma informed training to the community services sector. To find out more about our 1 or 2 day training packaged contact email@example.com
or call 02 8920 3611
National Strategy for Trauma Informed Care and Practice
Blue Knot Foundation is a foundation partner of a national Advisory Working Group (AWG) which is driving a national agenda around Trauma informed Care and Practice. A network of interested parties also been established. If you wish to join the TICP Network member, please email firstname.lastname@example.org
and provide your details so you can be included on the database.
TRAUMA INFORMED CARE AND PRACTICE ADDITIONAL RESOURCES
| The Buzz Newsletter | 28 February| NSW CAG’s 2011 Recovery Forum
Dr. Cathy Kezelman, Blue Knot Foundation President was the keynote speaker at the CAG (NSW) Annual Recovery Forum which focused on Trauma Informed Care. The following article is taken from The Buzz Autumn 2012 (Newsletter Mental Health and Drug and Alcohol Office). See page 9 of this article. To watch the presentation click here
| Trauma-informed Care and Practice Conference: Meeting the Challenge
Blue Knot Foundation co-hosted MHCC’s biannual Conference in 2011 - below are presentations and resources from the conference:
- Dr. Cathy Kezelman delivered a paper: Trauma Informed Care and Practice – changing the lives of Australian adult survivors of childhood trauma. To view the powerpoint slides click here. To watch the presentation on youtube click here.
- Prof Warwick Middleton, member of Blue Knot Foundation’s Advisory Panel gave an address in 4 parts “15 years directing a trauma and dissociation unit: perspectives on Trauma Informed Care”
- Professor Judy Atkinson, member of our Advisory Panel gave an address in 3 parts “An 'Educaring' approach to healing generational trauma in Aboriginal Australia”. Click here to read the powerpoint slides. Click here to watch the presentation.
- Dr. Richard Benjamin, member of our Advisory Panel gave 2 addresses, “Trauma Informed Care and Practice – engaging the left and the right hemispheres” – PART ONE (in 3 parts) and PART TWO (in 4 parts). Click here to read the powerpoint slides. Click here to watch the You Tube video.
Click here to see the other presentations and webcasts from the conference.
| MHS conference in Adelaide in September 2011 - Dr. Cathy Kezelman and Corinne Henderson, Senior Policy Officer MHCC co-presented a paper
“Trauma-informed Care and Practice-using a wide-angled lens”
To read the paper click here
. To view the Powerpoint slides click here
| The following podcast is a 1 hour interview which occurred as part of a 24 hour Talk-a-thon April 2011 "Breaking the silence that surrounds child sexual abuse"
The following interview
features Jenny Kelf, a counsellor/survivor and Dr. Cathy Kezelman, Blue Knot Foundation director, survivor, author.
Asking the question: What happened to you? Understand how the standard medical model of diagnosis often fails to heal patients by focusing on the obvious symptoms rather than the underlying cause. You'll receive an introduction to the idea of Trauma Informed Care and Practice across service systems.
| Click here
to read a Trauma Informed approach in the Family court system as a paper presented at a seminar "Child abuse in the Family Law System – a silenced epidemic”
co-convened by Justice for Children and National Child Protection alliance Nov 2011 at NSW Parliament House.
| Click here
to read an article by Cathy Kezelman entitled “Trauma Informed Care – Youth Mental Health”.
This paper was presented at a seminar in ACT “Creating a Culture of Prevention and Wellbeing”
Research shows that the relationship between childhood trauma and the development of borderline personality disorder (BPD) is well established (Giarratano, 2008). A high percentage of those diagnosed with BPD have a childhood history of abuse (Soloff, Lynch, & Kelly, 2002).
One of the most researched and effective treatments for BPD is dialectical behaviour therapy (DBT). DBT is considered an appropriate model for working with survivors of childhood abuse, and is considered by many as 'best practice' in helping clients (particularly those diagnosed with BPD) who engage in life-threatening behaviours to cope with intense and unstable emotions (Henderson, 2006). These behaviours include: self-harm, suicidal acts, impulsive behaviours such as substance abuse, eating disorders, or engaging in an unsafe lifestyle. DBT is a skill-based therapy developed by Dr. Marsha Linehan (Department of Psychology, University of Washington) that provides practical and effective coping techniques (Linehan, 1993a).
DBT is based on a cognitive behavioural approach and emphasises an acceptance of the person as he/she is, combined with the expectation that current behaviours need to change. The tension that arises between this need for both acceptance and change is known as a 'dialectical tension'. Dialectics is the practice of finding the middle ground between two opposites (Linehan, 1993a).
DBT is usually at least a one-year treatment, involving considerable commitment on the part of both therapist and client. Concurrently, the client learns techniques such as
mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance in a 'skills group', whilst undergoing individual therapy and receiving support (between sessions) via telephone consultations (Linehan, 1993b). This model is costly and primarily only available in Australia in the private sector, although a few agencies have begun piloting it in the public sector (Henderson, 2006).
DBT focuses on the acquisition of four core skills:
- Mindfulness: Mindfulness skills are psychological and behavioural versions of meditation practices from Eastern spiritual teachings. In DBT, three primary states of mind are presented: 'reasonable mind' 'emotion mind' and 'wise mind'. A person is in 'reasonable mind' when he/she approaches information and knowledge intellectually. The person is in 'emotion mind' when her/ his thinking and behaviour are controlled primarily by her/his current emotional state. 'Wise mind' is the integration of the 'emotion mind' and 'rational mind'. 'Wise mind' adds intuitive knowledge to emotional experience and logical analysis (Linehan, 1993b, p. 63).
- Interpersonal effectiveness: Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include acquiring effective strategies for asking to have one's needs met, saying no, and coping with interpersonal conflict. Individuals with Borderline Personality Disorder frequently possess good interpersonal skills in a general sense but problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioural sequences when discussing another person dealing with a problem, but may be completely incapable of generating or carrying out a similar behavioural sequence when analysing his or her own situation. The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g. requesting that someone do something) or to resist changes someone else is trying to make (e.g. saying no). The skills taught are intended to maximize the chances that a person's goals in a specific situation will be met, while at the same time not damaging either the relationship or the person's self-respect (Linehan, 1993b, p. 70).
- Emotional regulation: Individuals with Borderline Personality Disorder and those who are suicidal tend to be emotionally intense and labile. They can be angry, intensely frustrated, depressed/and or anxious. These clients can benefit from learning to regulate their emotions. Dialectical behavioural therapy skills for emotional regulation include:
- Identifying and labelling emotions
- Identifying obstacles to changing emotions
- Reducing vulnerability to emotion mind
- Increasing positive emotional events
- Increasing mindfulness to current emotions
- Taking opposite action
- Applying distress tolerance techniques (Linehan, 1993b, p. 84).
- Distress tolerance: Many current approaches to mental health treatment focus on changing distressing events and circumstances rather than on accepting, finding meaning for or tolerating distress. This task has traditionally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical Behavioural Therapy emphasises learning to bear pain skilfully. Distress tolerance skills have to do with the ability to accept, in a non-evaluative and non-judgmental fashion, both oneself and the current situation. Although the stance advocated is non-judgmental, it is not one of approval either: acceptance of reality does not equate with approval of reality (Linehan, 1993b, p. 96). Distress tolerance behaviours are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons (Linehan, 1993b).
As explained by Morgan (2000), narrative therapy promotes a core belief that individuals are the experts in their own lives while problems are separate from people. People have many skills, competencies, beliefs, values, commitments and abilities to help them reduce the impact of problems in their lives. By understanding and re-authoring, 'recovery' can occur through particular 'tellings' and 'retellings' of an individual's story. The narrative approach is interested in history and the broader context of people's lives (Morgan, 2000).
Michael White (1991) wrote that it is through narrative or stories that we learn about ourselves and others, and construct meaning of our experiences. He explained that stories shape how people live their lives as they largely determine which aspects of their experience people select for expression.
Consistent with the narrative approach, research shows that the meaning in the present assigned to past experiences may have a greater impact on the current functioning of the survivors than what actually happened (Giant & Vantanian, 2003). Therefore, in order for treatment to be effective, it is less important to determine the accuracy of the memories than it is to help the survivor deal with the meaning that she/he assigns to what she/he remembers about the experiences.
Narrative therapy for survivors is usually understood in the context of a feminist framework, with a strong belief in a collaborative approach. The therapeutic environment employs a feminist model focussing on principles of pluralism, egalitarianism and building on strengths. This creates an inclusive, safe and empowering environment that promotes shared decision-making. Participants are agents of their own process, while facilitators provide support (Asher et al., 1994, cited in Henderson, 2006).
Using Collaborative Narrative Group Work
A model of group work developed by van Loon & Kralik (2005b) uses a narrative framework to help make sense of issues participants perceive to be important. In describing the impacts of child sexual abuse the women in this study talked about many emotions and feelings but most commonly shame, blame, guilt, anger, fear and love. The group work sought to negotiate a less structured way to define these problematic feelings and explore them. The process focused on the way such feelings shaped the woman's view of herself and informed a life script which determined particular responses to those emotions, feelings and thoughts. Narrative processes were used to explore feelings and unpack the power dimensions and socio-cultural influences on the participants' feelings.
A narrative framework was used as a vehicle to make sense of each participant's life, and a narrative conversation was used to facilitate the quest for meaning and identity and to explore the ways participants view themselves within a social group and how they are viewed (van Loon & Kralik, 2005a).
Psychotherapy has been demonstrated to be valuable to adult survivors of childhood abuse (Price, Hilsenrothb, Petretic-Jacksonc, & Bongec, 2001), and to patients with Borderline Personality of which many are survivors of childhood abuse (Stevenson & Meares, 1992).
Psychotherapy is a broad term for a range of therapeutic models in which the therapist creates a 'safe space' within which individuals or groups can explore feelings, experiences and behaviours (and understand how they impact on the 'self'). The psychotherapeutic relationship, rather than any specific set of techniques is pivotal to the process (Kaplan, 1991, cited in Henderson, 2006). Psychotherapists understand the way the self of the therapist impacts upon the self of the client, and vice versa, and uses that knowledge to enable the client to explore their responses to relationships and the environment, and to make links with past experience. The relational framework upon which psychotherapy is based includes self, other, transference, countertransference, idealisation, empathic attunement, and emotional support and forms the basis for many 'talking therapies' and counselling models (Henderson, 2006).
A study by Stevenson & Meares (1992) evaluated the effectiveness of well-defined outpatient psychotherapy for patients with Borderline Personality Disorder and found that participants showed statistically significant improvement from the initial assessment to the end of the year follow-up on every measure. Moreover, 30% of the subjects no longer fulfilled the DSM-III criteria for Borderline Personality Disorder. This improvement had persisted one year after the cessation of therapy.
A study by Alexander & Anderson (1994) posits that attachment theory (and consideration of the nature of the parent-child relationship) provides a framework for understanding the wide array of symptoms and interpersonal problems exhibited by adult survivors of childhood abuse. Few studies relate the four main categories of adult attachment (secure, preoccupied, dismissing, and fearful/unresolved) to their anticipated effects in the therapy relationship. Drawing from research on adult attachment and clinical impressions of survivors, the authors present the probable therapeutic issues (including transference and countertransference) associated with each attachment category as well as suggested therapeutic strategies for dealing with clients from each.
INDIVIDUAL, COUPLE OR GROUP THERAPY
Group and individual therapy can be used independently or in conjunction for most survivors of abuse (Walker, 1994).
Individual Therapy has some advantages that group or family therapy does not provide. The major advantage is that the client has the individual attention of a trained professional for a certain reliable period of time.
Couples or family therapy
Couples or family therapy is another model of treatment available for adult survivors of childhood trauma and abuse. However, it is more suitable for later in the recovery process for several reasons. Firstly, most survivors have been betrayed by someone well known to them and have lost their ability to trust. This loss of trust and its accompanying hyper-vigilance to cues of potential danger make it difficult for a victim to perceive the neutrality or objectivity that is needed in family or couples therapy (Walker, 1994). Good family systems therapy demands that the therapist treat each attendant client equitably to establish an egalitarian atmosphere (Walker, 1994).
Group therapy is particularly well-suited to adult survivors who have already been in therapy, and have worked through their issues of trust. Ideally, group participants also have an individual therapist to help them process the material shared within the group (Henderson, 2006). Studies report group therapy to be beneficial for the psychological well being of adult survivors (de Jong & Gorey, 1996; Morrison & Treliving, 2002) and survivors themselves report that group settings which enable members to share traumatic material, and that provide safety, cohesion and empathy are helpful in the recovery process.
Studies assessing the effectiveness of group work for survivors include:
- Marotta & Asner (1999) conducted an integrated review of the literature and concluded that from the practitioner's point of view there is support for the effectiveness of group psychotherapy for survivors of incest.
- de Jong & Gorey (1996) synthesized the findings of seven published independent studies dealing with group work with female survivors of childhood sexual abuse, and compared the effectiveness of short-term versus long-term methods. The researchers concluded that 1) group work has large beneficial effects upon female survivors' affect and self-esteem-three-quarters of the group participants improve, 2) no extant empirical evidence supports the differential effectiveness of either short-term or long-term groups.
- A study by Kessler, White, & Nelson (2003) assessed the outcome research of 13 studies (six uncontrolled and seven controlled) on the treatment of adults who suffered childhood sexual abuse. The results generally indicate that group treatment helps reduce symptomatology in the short-term and at follow-up.
- Morrison & Treliving (2002) assessed the clinical outcomes of a slow open long-term dynamically-orientated group for abused adult males. 29 men participated in a group that explored themes such as identification with the aggressor, self-esteem, guilt and sexuality. The researchers found significant improvement in global scores, interpersonal sensitivity and depression in the group of 13 men who engaged in therapy for at least six months compared with those who did not.
- The Jacaranda project conducted by the Northern Sydney Sexual Assault Service between 2002 and 2004 provided group work for adult survivors of child sexual abuse and evaluated the intervention. Six 10-week groups were run, 5 for women and 1 for men. Quantitative Evaluation showed a substantial reduction in symptom intensity and symptom severity post group as well as a substantial reduction in negative cognitions. Qualitative analysis highlighted outstanding benefits for participants, including normalising experiences, improvements in physical health and well being, lessening of guilt and shame, improved understanding of sexual abuse and its legacies (Davidson, Kendall, Harsanyi, & Blyth, 2005).
- Buckingham & Parsons (2005) assessed a programme of time-limited therapeutic group work with female adult survivors of childhood abuse within the United Kingdom. The programme involved two separate groups, with a total of eight group members completing the test materials on the first and final group sessions and at a two-month post-treatment follow-up. Although it was a relatively small sample, the test results show a significant reduction in clinical symptoms and demonstrate the utility of this approach.
- van Loon & Kralik (2005b) developed a process of narrative group therapy that allowed women survivors of child sexual abuse to gain new perspectives and fresh insights into current problems/issues. The process allowed the women to seek linkages between current behaviour and responses, and past experiences. The women expressed that the group work helped them to make sense of their experiences and provided friends for the 'recovery' journey. Some of the women made strident progress in reclaiming their sense of identity and felt an improved sense of personal identity and autonomy, which led to a new sense of hope for a different future.
- Ziotnic et al. (1997) randomly assigned forty-eight female survivors with PTSD to either affect management treatment groups or a wait list. Findings suggest that an affect-management treatment group is a useful adjunct to individual psychotherapy and pharmacotherapy for survivors of child sexual abuse with PTSD.
- Wallis (2002) examined the effects of a group programme for the treatment of adults suffering the sequelae of childhood abuse and/or neglect. A total of 83 participants, comprising 64 women and 19 men, with 17 in the control group completed the Trauma Symptom Inventory prior to receiving treatment and three months later. This study showed that group therapy may have been an effective treatment modality for child abuse survivors. The level of sympomatology was reduced for those in the group program compared to those in the control group for whom there were no changes.
'Best Practice' regarding group work
A recent study by Palmer, Stalker, Gadbois, & Harper (2004) assessing 'what works for survivors of child abuse' found that both the professionalism of the workshop facilitators and the participants' relationship with the facilitators were particularly valuable elements. In addition, adult survivors reported that they valued the structured group treatment because it allowed them to process difficult emotions. A few survivors reported being upset hearing the stories of the other participants as well as by the conclusion of the group program.
Models of psycho-education groups for survivors
In a model developed by Maxine Harris (1998), 'the Empowerment Model' the core program consists of a series of thirty-three groups covering four topics: empowerment, trauma recovery, advanced trauma recovery issues, and closing rituals. Another model developed by Jon Allen (1995), 'the Psycho-education Model' was originally developed for a trauma education group at an inpatient 'trauma recovery program'.
For more information see:
Harris, M. (1998). Trauma Recovery and Empowerment: A Clinician's Guide to Working with Women in Groups New York: Free Press
Allen, J. (1995). Coping with Trauma: A guide to self understanding. Washington DC: American Psychiatric Press.
EVALUATING CLIENTS FOR TRAUMA THERAPY
When assessing new clients, it is important to assess current and past resources, attachment issues, physical and mental health history, drug and alcohol history and current usage (Rothschild, 2003). Clients should not be 'pressures' to disclose histories of abuse when they are not ready to do so. If a client chooses to disclose it is important to facilitate disclosure while ensuring the client does not become 'overwhelmed'.
Many therapists use instruments to assess current functioning such as:
- Impact of Events Scale (Weiss, 1996; cited in Rothschild, 2003)
- Somatoform Dissociation Questionnaire (SDQ-20) (Bijnenhuis, Spinhoven, van Dyck, van der hart & Vanderlinden, 1996; cited in Rothschild, 2003)
- The dissociative experience scale (Carlson, 1996; cited in Rothschild, 2003)
NEGOTIATING A TREATMENT PLAN
Some survivors prefer short periods of therapy with an option to extend when approaching the end of the specified time. This may occur for a number of reasons e.g. some survivors
- fear becoming dependent on the therapist
- fear being betrayed again
- may not fully grasp the process of therapy,
- or may need to keep some control. For such clients, 12 weeks is a good initial period as it does not seem long enough for the client to feel trapped, and it allows time to begin establishing the therapy relationship. Other clients prefer to have no limits set on the time available within the boundaries of the therapeutic relationship. It is important for the survivor to know that she/he can always seek a second opinion or discharge the therapist but that the therapist will not discharge her/him (Walker, 1994).
Realities around accessibility and affordability of therapy are also pertinent limiting factors.
A survivor of abuse will sometimes test the therapist to see if the therapist will abandon him/her if the trauma she/he describes is too aversive or she/he makes the therapist angry. The therapist needs to specify any limits on the behaviours she/ he will tolerate, near the beginning of treatment. It is also important to discuss the policy around telephone calls between therapy sessions, regularity of scheduled sessions, how to be contacted in an emergency, what constitutes an emergency, and so forth, need to take place (Walker, 1994).
Many survivors of childhood trauma and abuse injure their bodies in direct and indirect ways. In addition to cutting, burning, hitting, etc. self-harming behaviours include alcohol and drug addictions. Alcohol and drug addiction often go hand in hand with unsafe behaviours (drink driving, unsafe sex, dangerous drug deals, etc). The tendency to repeat patterns of trauma in violent relationships can be considered another form of self-harm. All of these behaviours possibly represent the survivor's attempts to manage or eradicate feelings, prevent memories, or re-enact some aspects of the abusive experiences (Saakvitne et al., 2000).
Safety when working with self-harming clients
With survivor clients, some of the hardest challenges of working in a model of empowerment emerge around issues of self-harm. 'Empowering clients' is especially hard when they are in hospital, in great distress, asking us to protect them, or suicidal (Saakvitne et al., 2000). Self-injurious behaviours make many of us want to take control and move to action.
Traditional models of working with adult survivors of childhood trauma and abuse often emphasise control of unusual or dangerous behaviours that are deemed as 'dangerous to self or others' or 'out of control'. When control takes precedence over collaboration, treatment systems may use and overuse restraints (physical or chemical), locked doors, contracts, denial or privileges, and withdrawal of treatment. These programs unwittingly substitute control for change (Saakvitne et al., 2000) and are often not trauma informed.
Many of our current practices around restraint, involuntary medication, and emergency room procedures create re-traumatising conditions (Saakvitne et al., 2000). Often such re-traumatisation could be reduced or avoided by consulting and working with the client as much as possible. Clients need to be included in the development of crisis response plans, with clear communication around your responsibilities and limits, seeking their help to develop the best possible plan to provide helpful responses when they are in crisis. When a discussion about safety occurs in the context of a relationship, the discussion is less about rules and more about collaboration and cooperation (Saakvitne et al., 2000).
Strategies for working with self harming clients
The first step is to distinguish between self-harming and suicidal behaviour by paying attention to the client's underlying motivation. When working with self-harming behaviour it is important to remember that this behaviour serves a purpose. In collaboration with the client, try to identify what problem self-harm solves for the client. For example, from the client's perspective:
- To make me feel real (counteracts dissociation)
- To punish me (temporarily lessens guilt or shame)
- To stop me from feeling (when strong feelings are too dangerous)
- To mark the body (to show externally the internal scars)
- To let something bad out (symbolic way to try to get rid of shame, pain, etc.)
- To remember
- To keep from hurting someone else (to control my behaviour and my anger)
- To communicate (to let someone know how bad the pain is)
- To express anger indirectly (to punish someone without getting them angry at me)
- To reclaim control of the body (this time I'm in charge)
The more the client and therapist understand the function of the behaviour, the more effective the intervention can be (Saakvitne et al., 2000). By identifying the underlying purpose, strategies to address the specific function of self-harm can be identified. For example:
- Need to mark body - draw on your body with a red marker
- Need to feel pain - hold ice against your body
- Need to feel in control - try breathing exercises
Blue Knot Foundation has conducted a review of the literature pertinent to working with adult survivors of childhood trauma and abuse. Empirical studies and clinical guidelines have been considered.
The following principles are important:
- Provide a safe place for the client
- Ensure client empowerment and collaboration
- Communicate and sustain hope and respect
- Facilitate disclosure without overwhelming the client
- Be familiar with a number of different therapeutic tools and models
- Views symptoms as adaptations
- Have a broad knowledge of trauma theory and provide the client with psycho-education
- Teach clients adaptive coping strategies (i.e. teach clients self-care, distress tolerance strategies and arousal reduction strategies)
- Teach clients to monitor their thoughts and responses
- Teach clients interpersonal and assertiveness skills
1. PROVIDE A SAFE PLACE FOR THE CLIENT
It is often only in a perceived safe environment that those who have been exposed to danger can let down their guard and experience the luxury of introspection and connection (Briere & Scott, 2006). Childhood trauma and abuse, at their core, are about being and feeling unsafe. A framework of physical, emotional and psychological safety is vital. Most people who have been abused need to regain their sense of safety (Briere & Scott, 2006).
Building a trusting relationship with someone who have experienced childhood trauma or abuse can be challenging. People who have been repeatedly hurt in interpersonal relationships have acquired a range of ways to guard against future harm. They are often vigilant, cautious, suspicious and/or angry and instinctively hide certain aspects of themselves and may mislead or block helpers from knowing them too soon (Saakvinte et al., 2000). It takes time for survivors to feel safe enough to reveal their feelings honestly in therapy and develop a trusting relationship with the therapist (Harper et al., 2007).
Even though many survivors may want to talk to their therapist about their feelings, their shame as well as fear of the therapist's response stops them from doing so (Harper et al., 2007). Health professionals need to be patient with survivor clients, and willing to wait until the client feels ready to reveal painful material.
Periodically checking with the client about his/her experience of the therapeutic relationship may help the client identify issues of mistrust. It also gives them permission to talk about what might be interfering with his/her ability to honestly express thoughts and feelings (Harper et al., 2007).
Building a trusting relationship between therapist and client is a prerequisite to addressing traumatic memories or applying any technique – even if that takes months or years (Rothschild, 2003). It involves helping the client loosen the defences they have used to cope with their trauma. If the therapy situation does not feel safe, a loosening of defences can lead to decompensation or even increase vulnerability to further harm (Rothschild, 2003).
2. ENSURE CLIENT EMPOWERMENT AND COLLABORATION
Saakvinte et al. (2000) stress collaboration and empowerment as key to working effectively with adult survivors. Survivors benefit most when they participate actively in their treatment and have control over decisions that affect them. For many survivors being cooperative and compliant can replicate feelings of being abused.
Interventions are more effective when they are developed collaboratively (Saakvinte et al., 2000). This can be very difficult when working with clients who are at risk of harm, at their own hands or by others, or at risk of harming others. Saakvinte et al. (2000) explain that collaboration requires acknowledging our responsibility to our clients and the power we have in the relationship while deferring to each client’s personal expertise and authority.
It is important for the client to take the lead in therapy (Harper et al., 2007). A study by Ullman et al. (2007) with survivors of childhood abuse found that a perception of control over the recovery process was associated with less distress.
Harper et al. (2007) conducted in-depth interviews with 30 survivors of child abuse six months after discharge from an inpatient trauma centre. This study found that therapists who were patient, understanding and respectful of survivors’ need for a sense of control in working towards their own solutions were viewed as most helpful. Survivors found it validating when therapists followed the client’s direction as opposed to leading them or pressuring them to follow a specific course of action. Maintaining a sense of control over which therapeutic issues were addressed, and when, helped the survivors manage overwhelming feelings better, and was identified as important. Many participants in this study felt it crucial that their therapists allowed them to reach their own solutions in their own time. Some participants found it helpful to be allowed to focus on present day situations; others found it helpful to focus on abuse-related feelings. Participants also appreciated therapists who gave them choices, and who acknowledged participants’ insights and ideas about their own recovery. A woman noted with reference to her psychiatrist, “She always asks me, and gives me a choice; ‘Well, do you want to go this way, do you want to go this way?’ So, she makes sure that I'm in control of everything”.
It is important that therapists recognise the abuse survivor’s competence to make decisions and to develop solutions (Harper et al., 2007). It is especially important that therapists do not assume that adults abused as children are fragile; they need to refrain from doing for survivors what survivors can do for themselves (Harper et al., 2007). As child abuse survivors have often been taught to attend exclusively to others while dismissing their own needs, it is important to encourage them to value their own needs, honour their own ideas, and become the directors of their own therapy (Harper et al., 2007).
In a crisis situation, ask the client to work with you to make things safer. If the individual must be contained to achieve safety, encourage his/her help or participation. It is always valuable to say what you are going to do before you act and to ask if a client can do it him/herself. The more you can include a client in the process, the more the process becomes a way of helping a client expand his/ her repertoire of coping skills and increasing his/her sense of personal control over his/her own actions and environment. The more you name what is happening and invite the client’s collaboration towards achieving safety, the more you differentiate the present from past abuses of power. After a crisis intervention, there should always be a debriefing with the client to discuss what was helpful and what could have been done differently (Saakvinte et al., 2000).
3. COMMUNICATE AND SUSTAIN HOPE AND RESPECT
It is vital to communicate and sustain hope and respect when working with adult survivors of childhood trauma and abuse (Saakvinte et al., 2000).
The health professional’s respect for the client is conveyed in many ways, including:
- Forms of address
- Respect for confidentiality
- Sensitive use of language
- Admitting when you have made a mistake or feel unsure
- Assuming that the client as well as the health professional have valid points of view (Saakvinte et al., 2000).
Helping professionals who work with survivors serve as trustees for survivors' future possibilities. In our words, actions, and body language, we communicate hope. While it’s important to empathise with the survivor’s current hurt and despair, it is important to hold onto visions of the survivor’s potential future self (Saakvinte et al., 2000).
Rothschild (2003) stresses the role of ‘hope’ and the importance of identifying and building on the client’s internal and external resources. She explains that it is important to help the client identify the resources he/she already possesses (such as: a sense of humour and defence mechanisms, interpersonal resources such as friendships, family, pets, belief system, etc.).
4 FACILITATE DISCLOSURE WITHOUT OVERWHELMING THE CLIENT
4.1 To disclose or not to disclose?
Disclosure for survivors of child abuse may bring their abuse story back to the surface, and this can be very overwhelming (Harper, Stalker, Palmer, & Gadbois, 2007). Facing memories and experiencing flashbacks can be painful and/or overwhelming, and can trigger automatic childhood responses such as running away, avoidance or denial (van Loon & Kralik, 2005c). Some professionals who feel there is nothing to be gained by going back over past experiences, nor delving into them. Others believe that disclosure externalises those past experiences, and disentangles the issues they invoke from who the survivor really is, making it possible to separate the survivor from the abuse experiences (van Loon & Kralik, 2005c).
Some survivors find disclosure helpful, others do not. If a survivor does not want to disclose, they may not be ready, or this may not be a necessary part of their ‘recovery journey’.
For example, the survivor participants in a study by van Loon & Kralik (2005b) concluded that their needs in respect to disclosure varied. Some survivors found that they did not need to dig too deep because the process of exploring could become re-traumatising. Others explained that it was important to acknowledge that the abuse happened and speak about the aspects of the abuse story that related to the impacts of the abuse, rather than the details of what happened. Survivors should never be ‘forced’ to disclose their past experiences.
Survivors who participated in a study by Harper et al. (2007) also hold differing experiences. Some found it important to explore the past; others found it helpful to move on from the past and focus on present day issues.
4.2 Barriers to disclosure
The survivors in the study by van Loon & Kralik (2005a) noted that they minimised, discounted and ignored the fact they had been sexually abused during childhood, or for most of their lives. The reasons for this varied, but they included shame and embarrassment; fear of retaliation from the perpetrator and concern that they would not be believed. This led to many women discounting their experiences, denying they happened or choosing to block them out.
Barriers that prevent survivors from seeking help (and inhibit disclosure) include:
Many survivors use the protective defences learned in childhood such as denying, minimising, or dissociating to cope with their situation (van Loon & Kralik, 2005a). Complete or partial denial, minimization, and even total repression of the abusive event/s inhibit the survivor’s ability to seek and receive help. These strategies keep the survivor from knowing just how terrible things actually are. Changes in the survivor’s ability to think clearly are not easily observed when patterns of covering up are ingrained as survival skills (Walker, 1994).
Another coping strategy commonly used by survivors of childhood abuse is ‘pleasing and compliant behaviour’. Survivors of childhood abuse learn to anticipate the emotional reactions of another person to their behaviour. They have learned that pleasing the abuser is one way to reduce the amount of abuse. Preventing the abuser from seeing how emotionally upset they are (sometimes because the abuse will be worse if they show their feelings) is a coping strategy. This need to please and to follow directions may be carried over into the therapist’s office. Such clients want to be liked and to please, feeling that the therapist will protect them if they are ingratiating. It is important to understand the significance of this behaviour and to respond sensitively, respectfully, and helpfully (Walker, 1994).
Self-blame is another common sequela of abuse. The survivor holds her/himself accountable for the victimization: If she/he had not done something wrong, then the abuse would not have occurred. This attribution helps the survivor retain the illusion that she/he has power and control over not being hurt again (Walker, 1994).
Shame and guilt
Shame and guilt are common sequelae of abuse. Shame and/or guilt can make it difficult for the survivor to seek or to accept help. Shame is the internal feeling that comes from being exposed and vulnerable, whereas guilt is an externally imposed feeling that comes from believing that something wrong was done (Walker, 1994). Survivors of child abuse may experience guilt because they may have been blamed for the abuse. Survivors of childhood abuse may even think they ‘asked for it’, ‘invited it’ or ‘deserved it’ (van Loon & Kralik, 2005a). Survivors may be experiencing hurt, embarrassment and shame over what happened, so it seems easier to remain silent about the incident (van Loon & Kralik, 2005a).
The ability to hide one’s true feelings
Most treatment approaches are highly dependent on cognitive understanding and insight into one’s thought processes, affective responses, and behaviour. Many women have learned how to hide their true thoughts and feelings from scrutiny, allowing only those consistent with mainstream culture to be viewed by others. This ability to hide one’s real thoughts and feelings is frequently enhanced by the impact of abuse. After all, safety from further abuse may seemingly depend on the ability to keep the abuse secret, sometimes even from oneself (Walker, 1994).
Fear of punishment from the perpetrator
Perpetrators may actively and aggressively attempt to block the survivor’s access to any help (Walker, 1994). Fear of the perpetrator’s threats, punishment, rejection, negative reactions, being treated differently, upsetting parents or breaking up the family also inhibit access to help (van Loon & Kralik, 2005a).
Fear of the therapist’s response
Many survivors fear that no one will believe them, that their account of the abuse will be dismissed as a fabrication, an exaggeration, or an attempt to evade the true work of psychotherapy (Walker, 1994).
Survivors may feel especially confused if some aspects of the abuse felt enjoyable, exciting and sensually stimulating. In addition, possible mixed emotions of love for the perpetrator and hate for what they have done may also inhibit access to help (van Loon & Kralik, 2005a).
Difficulties putting trauma into words
The relationship between the difficulties expressing traumatic events in language experienced by some survivors of childhood abuse and the brain’s neural connections has been explored by a number of researchers (for example, MacKay, 2008). Research shows that a less developed trauma narrative hinders recovery from trauma (Amir, Stafford, Freshman, & Foa, 1998). During states of high arousal (such as danger) the area of our brain responsible for speech becomes inhibited, which results in a diminished capacity for language in certain situations (Cozolino, 2008). This is a high price for humans to pay for being afraid. Putting our feelings into words and constructing narratives of our experiences contribute invaluably to emotional regulation, the integration of neural networks of emotion and cognition, and the experience of a coherent sense of self (Cozolino, 2008).
Fear of being ridiculed or not believed
Many adult survivors of child sexual assault speak of their experiences of being blamed, ridiculed, or shunned, when they tried to disclose (van Loon & Kralik, 2005a).
4.3 Responding appropriately and safely to disclosure
A primary goal of self-trauma therapy is to avoid overwhelming the client, while at the same time facilitating exposure to traumatic material so it can be desensitised and integrated (Briere, 2004). Effective therapeutic responses occur on a continuum, between interventions devoted to a greater awareness of potentially threatening, but therapeutically important material (exposure), and those that support and solidify previous progress (consolidation). Consolidation is concerned with safety and involves activities that reduce arousal and ground the client in the here and now (Briere, 2004).
‘Active listening skills’
Most survivors of abuse find talking, in general, cathartic and talking about the pain caused by their abuse history useful in particular. Therapists who listen to the survivor, ask clarifying questions, name the survivor’s experiences, and do not overly challenge what the survivor says, help the survivor make the most progress. Once the relationship is well-established, it may be appropriate to offer interpretations, but until then, it is most therapeutic to point out contradictions but not offer opinions as to their possible psychological origins. Active, direct participation in validating the survivor’s perceptions, feelings, and experiences, in addition to acknowledging the information being shared, and checking to make sure it is appropriately understood, are all important parts of treatment. Often, simply repeating what the survivor has said out loud helps to validate her/his thoughts and feelings in ways that they have never been validated before. Simple but powerful, this may be the best approach a therapist can take even if the survivor is not ready to deal with other issues at that time (Walker, 1994, van Loon & Kralik, 2005a).
In addition, research shows that ‘ignoring the disclosure’ or ‘rushing them’ is experienced as particularly harmful by survivors of child abuse (Josephson & Fong-Beyette, 1987). Elie Wiesel a Holocaust Survivor is quoted as saying “What hurts the victim most is not the cruelty of the oppressor, but the silence of the bystander”. This is also true for the survivor of childhood abuse who discloses and is met with silence, or tells and is not believed, or tells and sees no further supportive action as a result of disclosing (cited in van Loon & Kralik, 2005a).
5 BE FAMILIAR WITH A NUMBER OF DIFFERENT THERAPEUTIC TOOLS AND MODELS
It is important to adapt the therapy to the client, rather than expecting the client to adapt to therapy. This requires the therapist to be familiar with several theories and treatment models (Rothschild, 2003). Rothschild (2003) explains that competition regarding the superiority of one method or model over another is fierce in trauma therapy. This trend puts clients in a difficult position: Should they prioritize choosing a method or is it more important to find a practitioner who is a good fit? Too many trauma therapists offer only one technique and this limitation can compromise client commitment when that particular method fails. It is important for therapists to be trained in several treatment modalities so that treatment plans can be tailored to the needs and tastes of the client
6 VIEW SYMPTOMS AS ADAPTATIONS
It is important to view the client’s current behaviour in light of their abuse history. The essence of a trauma model is recognition of the trauma in relation to the current behaviour, and recognition of trauma symptoms. It is important to focus on encouraging a change in how the client interprets his/her symptoms and maladaptive behaviours (Harper et al., 2007). It is the health professional’s responsibility to reframe the client's responses to the abuse. It is important to understand that the coping strategies survivors used as a child were functional for the child-victim dealing with the abuse, but may not be helpful in present life situations. Reframing feelings and behaviour as coping strategies that were adaptive to surviving past abuse can be the beginning of positive change. A study by Harper et al. (2007) showed that survivors find it helpful when professionals help them see the connection between their current symptoms and behaviour, and their history of abuse (Harper et al., 2007). Participants emphasized that it was very helpful to their recovery process when therapists assisted them to understand their feelings and coping strategies in the context of their specific abuse history (Harper et al., 2007).
7 HAVE A BROAD KNOWLEDGE OF TRAUMA THEORY (BOTH THE PSYCHOLOGY AND PHYSIOLOGY OF TRAUMA) AND PROVIDE THE CLIENT WITH PSYCHO-EDUCATION
In the literature, much attention is paid to the cognitive and emotional processing of traumatic memories. Psycho-education is an important aspect of trauma therapy (Briere & Scott, 2006). Health professionals can assist survivors by providing accurate information about the nature of trauma and its effects, and by working with the survivor to integrate this new information and its implications into his/ her overall perspective (Briere & Scott, 2006).
Rothschild (2003) explains that by understanding how the brain and body process, remember, as well as perpetuate traumatic events, the client learns how to regulate affect and pain.
Survivors of childhood abuse find it helpful when their therapists help them relate their intense feelings and maladaptive coping strategies to the trauma. Survivors who participated in the study by Harper et al. (2007) emphasized that it is very helpful when their therapists were knowledgeable about PTSD and trauma-focused treatment. Participants appreciated when their therapists researched new information and techniques, and informed them accordingly. It is important, therefore, that professionals understand the psychological effects of trauma.
To figure out the best way for clients to use reading materials, talk with them about their individual learning styles. What have they read already? How did the reading affect them? Encourage them to notice their reactions, thoughts, and feelings, and to stop reading if they feel distressed or overstimulated. Give clients the opportunity to talk with you about what they have read and their response to the material.
8 TEACH CLIENTS ADAPTIVE COPING STRATEGIES
Even though childhood coping mechanisms were functional at the time of the abuse, many are no longer constructive in present life situations. Therefore, it is important to teach survivors of child abuse more adaptive coping strategies. It is important to help survivors develop more adaptive coping strategies rather than risking making matters worse by getting rid of clients’ maladaptive defences and leaving them with no coping strategies. Rothschild (2003),
A study by Harper et al. (2007) found clients rated professionals helpful when they could reinforce or teach strategies for managing the intense affect associated with traumatic childhood abuse.
Clients can be taught more adaptive coping strategies by teaching them self-care strategies, distress tolerance strategies, and arousal reduction strategies. Research into the adverse impact of child abuse on brain development and hormone secretion, highlights the importance of engaging in self-care, and arousal reducing activities to promote healthy neuro-endocrine functioning.
The link between a history of childhood abuse and neglect, and neuro-endocrine impacts, including alteration in cortisol production, has been well established (Joyce et al., 2007; Linares et al., 2008). The neuro-endocrine system refers to the system of interaction between our brain/nervous system and the hormones in our bodies. This system helps regulate our moods, our stress response, our immune system, and our digestion, amongst other things. Any disruption to the neuro-endocrine system affects a range of basic psychological and physiological functions. Research suggests that many of the long-term impacts of child abuse experienced by adult survivors result from the chronic neuro-endocrine dysregulation caused by prolonged exposure to abuse and violence (Kendall-Tackett, 2001). Neuro-endocrine dysregulation, in particular an overproduction of the stress hormone, cortisol, may contribute to the difficulties some survivors of childhood abuse experience in tolerating distress.
Research tells us that the bodies of children who are being abused react and adapt to the unpredictable, dangerous environments to which they are exposed. Their nervous systems run constantly on high as they anticipate further danger; this floods the body with fight-or-flight hormones Cozolino (2002). For example, a study by Linares et al., (2008) shows a neuro-endocrine alteration in cortisol production in children with histories of abuse and neglect. This state of chronic “hyper-arousal” persists for many survivors throughout their adult years as well. Even when the abuse and violence has ceased and the environment is ‘safe’, many adult trauma survivors still perceive the threat to be present; their fear is maintained and becomes pathological (Giarratano, 2004b). Research shows high cortisol levels in adult survivors of childhood abuse. A study by Joyce et al. (2007) found that mothering styles that were high in control but low in affection, childhood sexual and physical abuse were all associated with high cortisol levels in depressed adult survivors.
The good news is that a range of interventions and skills can promote healthy neuro-endocrine function. Engaging in activities that reduce stress, such as self-caring activities, distress tolerance strategies, arousal reducing strategies, etc., has been shown to normalise the nervous system and balance hormone levels.
8.1 Teach clients self-care strategies
Self-caring activities and learning how to soothe themselves emotionally are important skills for survivors. Engaging in self-care activities can be especially challenging for survivors who may have never learned to ‘self-soothe’ or ‘self-care’. In the act of neglecting, hitting, insulting or abusing a child, an adult sends a clear message to that child that the child is without value or worth. Many abused children grow to adulthood believing that they do not deserve to experience love, care or warmth. In addition, parents who abuse are often poor at soothing themselves and, consequently, at teaching their children to self-soothe (The Morris Center, 1995). Learning self-care can be a challenge for adult survivors of child abuse, since it requires survivors to develop a radically new understanding of themselves as human beings with the right to feel comfortable, safe and worth-while.
To strengthen clients’ sense of self acceptance and self care some of the following strategies can be recommended:
- Call someone (crisis line, clergy, sponsor, therapist, case manager, friend)
- Think of someone you trust and imagine a comforting conversation with him/her
- Keep a list of people you can call in an obvious place; look at it when feeling alone; call someone on it
- Write a letter
- Repeat affirmations (“I deserve to live,” “I deserve to be treated kindly”)
- Remember that being treated badly in childhood was not fair and you deserve to have it different now
- Do something that makes you feel better about yourself; garden, help someone else, cook, be productive, work on a charitable or political project.
8.2 Teach clients distress tolerance strategies
Saakvinte et al. (2000) explain that childhood abuse interrupts the normal development of a person’s ability to identify and regulate their feelings. In this light, a number of trauma frameworks emphasise the importance of learning skills to regulate feelings (Briere, 2004; Linehan, 1993a; Saakvinte et al., 2000). In the absence of adequate affect regulation skills, even small amounts of distress may be experienced as overwhelming and thereby motivate avoidance (Briere, 2004).
The possible over-production of the stress hormone, cortisol may contribute to the difficulties tolerating distress experienced by some survivors of childhood abuse. In addition, most survivors never learn to self-soothe in childhood because parents who abuse are also often poor at soothing themselves and, consequently, at teaching their children to self-soothe (The Morris Center, 1995). The lack of childhood ‘nurturing’ experiences, and the lack of being taught how to look after yourself or ‘self-soothe’ also contributes to difficulties tolerating distress. Acquiring distress tolerance strategies or self-soothing techniques are important for those with histories of childhood abuse.
Many current approaches to mental health treatment focus on changing distressing events and circumstances. They pay little attention to accepting, finding meaning for, and tolerating distress. Dialectical behavioural therapy emphasizes learning to bear pain skilfully (Linehan, 1993b, p. 96). Distress tolerance skills have to do with the ability to accept, in a non-evaluative and non-judgmental fashion, both oneself and the current situation. Although the stance advocated is a non-judgmental one, it is not one of approval: acceptance of reality is not approval of reality. Distress tolerance behaviours are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons (Linehan, 1993b).
8.3 Teach clients arousal-reduction tools i.e. always ‘reduce the pressure’
In situations of early childhood abuse, the trauma and shock of the abuse interferes with the ability to regulate emotions, causing frequent episodes of extreme/out of control emotions, including anger and rage (Linehan, 1993a). Arousal-reducing tools can assist survivors in regulating their emotions.
As explained previously, a state of hyper-arousal is a natural response to a dangerous situation or threat. Many survivors of trauma remain in a constant state of alarm because the fight/flight response is triggered repeatedly (Giarratano, 2004b), and without evident purpose (Cloitre, Cohen, & Koenen, 2006). A state of hyper-arousal may include feelings such as anger or anxiety.
A state of anxiety is common among trauma survivors because it is typically generated by experiences that are unpredictable, uncontrollable, or unfamiliar, i.e. the characteristics of trauma or danger. Anxiety ensures readiness for coping with an unidentified danger (Cloitre et al., 2006) and so has an adaptive function. This may be because multiple, unidentified trauma reminders exist in the environment that trigger anxiety, or because trauma causes survivors to psychologically, and biologically, adapt to ‘living in a dangerous world’ (Cloitre et al., 2006). Teicher (2002) explains that early exposure to stress creates molecular and neurobiological change, altering neural development so the adult brain can survive in a dangerous world.
Anger is usually a central feature of a survivor's response to trauma because it is a core component of the survival response in humans. Anger helps people cope with life's adversities by providing increased energy to persist in the face of obstacles. High levels of anger are related to a natural survival instinct (Chemtob, Novaco, Hamada, Gross, & Smith, 1997).
Symptoms caused by hyper-arousal include:
- Having a difficult time falling or staying asleep.
- Feeling more irritable or having outbursts of anger.
- Having difficulty concentrating.
- Feeling constantly ‘on guard’ or like danger is lurking around every corner.
- Overbreathing, hyperventilating
- Being ‘jumpy’ or easily startled (Giarratano, 2004a)
8.3.1 The importance of always reducing ‘the pressure’
When working with survivors of childhood abuse, it is important to use arousal reducing techniques or, as explained by Rothschild (2003), to ‘reduce the pressure’. Rothschild (2003) draws on an understanding of the physiology of the brain and how it responds to danger, emotion and traumatic events, to illustrate the hazards of addressing traumatic material before the client is equipped to manage the process. She explains that traumatic memory can be easily triggered, accelerating hyper-arousal out of control, causing intense physical symptoms and/or flashbacks. Until triggers are identified, they are unpredictable. In order for clients to feel safe in life and therapy, they need to be equipped with tools to help them contain reactions to therapy and triggers, and to halt the out of control acceleration of hyper-arousal. Being able to apply the brakes aids clients in daily life, and also gives them the courage to address difficult issues (Rothschild, 2003). Rothschild (2004) stresses the importance of never helping clients call forth traumatic memories unless the therapist and client are both confident that the flow of anxiety, emotion, memories, and body sensations can be contained.
Arousal-reduction strategies make it possible for clients to have control over their traumatic memories, rather than feeling controlled by them (Rothschild, 2004).
Knowing when to ‘apply the brakes’ is as important as knowing how. The timing can be gauged by watching for physical signals of autonomic system arousal transmitted by the client’s body, tone of voice and physical movements (Rothschild, 2004). When the client turns pale, breathes in fast, takes panting breaths, has dilated pupils, and shivers or feels cold, the part of the nervous system that is activated in states of stress (i.e. the sympathetic nervous system) is aroused. Stress hormones are pouring in. These symptoms mean it is time to calm the client down. When a client sighs, breathes more slowly, sobs deeply, or flushes the part of the nervous system that is activated in states of rest and relaxation, the parasympathetic nervous system, has been activated, and stress hormone levels are reducing (Rothschild, 2004).
Physiology of the brain
As explained previously, the limbic system (amygdala and hippocampus) is the area of the brain that initiates the fight, flight or freeze responses to perceived threat. The cortex (the more rational, outer-layer of the brain) is the seat of our thinking capacity. The cool, rational cortex is in constant communication with the amygdala and the hippocampus. The amygdala processes emotions before the cortex gets the message that something has happened. For example, the sound of a loved one’s voice is communicated to the amygdala, and the amygdala generates an emotional response to that information (for example, pleasure) by releasing hormones. When someone is threatened, the amygdala perceives danger and sets in motion a series of hormone releases that lead to the defensive response of fight, flight or freeze. The hippocampus helps to process information and assists in the transfer of initial information to the cortex which works to make sense of the information. The hippocampus is vulnerable to stress hormones, in particular the hormones released by the amygdala’s alarm. When those hormones reach a high level, they suppress the activity of the hippocampus and it loses its ability to function. Information that would make it possible to differentiate between a real threat and an imagined threat never reaches the cortex meaning that a rational evaluation of the information isn’t possible. Therefore, the amygdala continues to sound an alarm inappropriately.
As such, safe and successful trauma therapy needs to maintain stress hormone levels low enough to keep the hippocampus functioning (Rothschild, 2004).
8.3.2 Arousal Reducing Strategies
Distracting your thoughts
Exercises designed to distract can be helpful when attempting to reduce states of hyper-arousal (e.g. anger, anxiety).
Breathing control exercises
Increased respiration is one of the body’s fight/flight responses. Trauma survivors whose response is firing too rapidly can chronically over-breathe. This can lead to hyperventilation and may contribute to panic attacks in some people (Giarratano, 2004b). Controlled breathing techniques are used to slow the respiration rate. Our breathing rate has an impact on our heart rate, blood pressure and the rest of our body. Breathing at the correct rate slows the bodily processes, lowers arousal, and in turn reduces tension and stress. Slowing the breathing rate is an effective method of turning off the ‘fight/flight’ response. The breathing rate normally increases in the presence of a perceived threat.
It is helpful to use controlled breathing techniques at the first sign of anxiety or panic. It might be helpful for clients to use these techniques before tackling difficult situations, and anytime they are feeling tense or anxious
9 TEACH CLIENTS TO MONITOR THEIR THOUGHTS AND RESPONSES
Cognitive Behavioural Therapy (CBT) can be an effective tool with trauma survivors. CBT works with cognitions to change emotions, thoughts and behaviours. The goal is to understand how certain thoughts cause stress and make symptoms worse. CBT for trauma includes learning how to cope with anxiety and negative thoughts; managing anger; preparing for stress reactions; handling future trauma symptoms; addressing urges to `self-soothe' with alcohol or drugs and communicating and relating effectively with people (National Centre for PTSD, 2008). The CBT model, when used with survivors of child abuse, usually focuses on the ‘here and now’ rather than on revisiting the trauma itself (Henderson, 2006).
10 TEACH CLIENTS INTERPERSONAL AND ASSERTIVENESS SKILLS
A child should not equate his/her dependence on an adult for nurture, safety, love and connection with taking a risk. Once betrayed however, future attachments and interpersonal connections do require risking disappointment and perhaps shame, neglect and/or abuse. In adulthood, survivors of childhood abuse often find it risky to make connections between their past and present, their thoughts and feelings. Most survivors need the support of interpersonal connections to restore meaning and wholeness in their lives (Saakvinte et al., 2000).
Impairments in interpersonal relationships are of crucial importance for understanding the effects of child abuse on mental health outcomes. Research consistently shows that child abuse is linked with difficulties in interpersonal relationships. In a study by Collishaw et al. (2007) almost half of those reporting abuse in adulthood showed significant abnormalities in interactions with peers in adolescence. At the same time, peer relationships in adolescence emerged as one of the strongest predictors of resilience within the abused group. This study found that only those individuals with good relationship experiences across childhood, adolescence and adulthood are likely to demonstrate resilience. Collishaw et al. (2007) explain that children who have experienced abuse are less likely to bring positive expectations or interpersonal strategies to a relationship. Instead they may see others as untrustworthy and unpredictable, and relationships as a potential source of conflict rather than a source of support and enjoyment.
A core component of DBT (dialectical behaviour therapy) is teaching clients interpersonal response patterns. These skills are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include:
effective strategies for asking for what one needs
saying no, and
coping with interpersonal conflict
Linehan (1993b) suggests that it is helpful for interpersonal skills’ training to focus on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The aim is to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect (p. 70).
Research indicates that service providers often find treating survivors of childhood abuse stressful, because of survivors' resistance to change, their ways of relating to helpers, and the nature of the work (Palmer et al., 2001). The nature of the work is particularly stressful when it involves listening to detailed descriptions of very painful, often horrific events; it may also involve helpers re-enacting survivors' early experiences of trauma and betrayal with them (Palmer et al., 2001). There is no doubt that hearing and thinking about the stories one hears can continue well after the client has left the therapeutic interaction.
Historically, therapists' reactions to client traumas were regarded as either burnout or countertransference. These days, the term vicarious traumatisation (VT) is used to describe therapists' trauma reactions resulting from exposure to clients' traumatic experiences (Figley, 1995; Pearlman & Maclan, 1995; Trippany, White Kress, & Wilcoxon, 2004).
VT is defined by Saakvitne et al. (2000) as the cumulative transformative effect on the helper of working with survivors of traumatic life events, both positive and negative. VT recognises that working with trauma survivors greatly affects the helper and that we must address the effects in order to protect both helper and clients. VT is unavoidable and is the natural consequence of being human, connecting to and caring about our clients as we see the effects of trauma on their lives (Saakvitne, Gamble, Pearlman, & Tabor, 2000). According to Saakvitne et al. (2000) the single most important factor in the success or failure of trauma work relates to the attention paid to the experience and the needs of the helper. We cannot meet the needs of our clients when we are overriding our own.
Saakvitne et al (2000) explain that inevitably trauma therapists will develop an increased awareness of the reality and occurrence of traumatic events, and this makes therapists more aware of their vulnerability. Safety and security are threatened when therapists become aware of the frequency of traumas, often leading to feelings of loss of control and helplessness. VT can affect how therapists relate to their families, friends, and partners. Furthermore, the therapist may experience changes in esteem for themselves and for others.
Signs and symptoms of vicarious traumatisation (Saakvitne et al., 2000).
VT impacts on areas of psychological need including: safety, trust, esteem, intimacy and control.
Signs and symptoms of VT include:
- Emotional numbing
- Social withdrawal
- Work-related nightmares
- Feelings of despair and hopelessness
- Loss of sense of spirituality
- More negative view of the world
- Reduced sense of respect for your clients
- Loss of enjoyment of sexual activity
- No time or energy for yourself
- Feeling that you can't discuss work with family or friends
- Finding that you talk about work all the time (can't escape)
- Sense of disconnection from your loved ones
- Increased sense of danger (reduced sense of safety)
- Increased fear for safety of children or loved ones
- Sense of cynicism or pessimism
- Increased illness or fatigue
- Increased absenteeism
- Greater problems with boundaries
- Difficulties making decisions
- Reduced productivity
- Reduced motivation for your work
- Loss of sense of control over your work and your life
- Lowered self esteem, lowered sense of competence in your work
- Difficulties trusting others
- Lessened interest in spending time alone
- Less time spent reflecting on your experiences
Managing vicarious traumatisation
The trauma model CSDT (constructive self development theory) for working with survivors of childhood trauma outlined previously, is also a useful model for assisting therapists and trauma counsellors to manage their VT experiences. CSDT suggests that changes in the perceived realities of therapists occur as a result of working with traumatised clients and their stories (Saakvitne et al., 2000). Strategies to manage VT as suggested by Saakvitne et al. (2000) include:
1. Anticipating VT and protecting oneself:
Protecting yourself includes arranging things ahead of time to anticipate the stress of your work and its impact on you. Strategies include:
A sense of balance is considered to be one of the key components to preserving a sense of identity and overall wellbeing. A healthy balance of work, rest, play, including socialisation with friends and family is important in decreasing the effects of VT. Furthermore, any activities which assist the individual's personal tolerance levels, for example; journal writing; personal counselling; emotional support from partners, will assist the individual to reconnect to emotions (Trippany et al., 2004).
2. Addressing signs of VT
Addressing VT includes those things you do for self-care. Strategies include:
- Self nurturing
3. Transforming the pain of VT
Transforming VT includes things you do to transform the negative impact of the work into a connection with some positive aspects of meaning and community. Strategies include:
- Create meaning
- Infuse meaning in current activities
- Challenge negative beliefs
- Participate in community building
Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery
Blue Knot Foundation’s Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery present the collective wisdom of the last two decades of national and international research in the trauma field. They are poised to revolutionise possibilities for recovery for the large numbers of people with unresolved "complex trauma" - child abuse in all its forms, neglect, family and community violence and other adverse childhood events. They establish insights that optimism about recovery from complex trauma is warranted, and that childhood trauma can be resolved.
Register & download full document
2013 | Trauma Informed Care and Practice Policy Reform
Dr. Cathy Kezelman, Blue Knot Foundation President was co-author on the MHCC document: Mental Health Coordinating Council (MHCC) 2013, Trauma-Informed Care and Practice: Towards a cultural shift in policy reform across mental health and human services in Australia, A National Strategic Direction, Position Paper and Recommendations of the National Trauma-Informed Care and Practice Advisory Working Group, Authors: Bateman, J & Henderson, C (MHCC) Kezelman, C (ASCA).
The Position Paper is informed by extensive international and national evidence and the work of the National Trauma-Informed Care and Practice Advisory Working Group (NTICP AWG). It provides a platform from which MHCC and Adults Surviving Child Abuse (ASCA) are advocating broad-based policy reform to embed trauma-informed principles of practice across jurisdictions and sectors; in organisations, service delivery and professional practice. The paper incorporates the recommendations of the NTICP AWG needed to facilitate a strategic approach towards a cultural shift in policy reform in mental health and human services in Australia.
Download Position Paper
The following are a snapshot of some of the presentations, forums and webinars involving ASCA in recent years
Nov 2013 | Forum convened by ASCA, MHCC and NSW Mental Health Commission
The following presentations were featured in this forum:
August 2013 | Trauma, Trauma Frameworks and Being "Trauma Informed"
- Lucas, J (2013)Wesley Mission, Trauma-Informed Care & Practice Forum, MHCC, ASCA & the NSW Mental Health Commission, Sydney November 2013 - "A Journey"
On the 7th August 2013 the Domestic Violence Clearinghouse convened a forum about trauma-informed practice, jointly hosted with the Australian Centre for Study of Sexual Assault (ACSSA). Dr Cathy Kezelman, President of Adults Surviving Child Abuse (ASCA) delivered a keynote address, before the panel discussed a range of issues around dealing with trauma and the need to be 'trauma-informed' in practice situations. A Q&A session allowed practitioners and service representatives to further engage the panel on a range of important issues.
Download all presentations Download Dr Kezelman's presentation
Nov 2011 | Dr. Cathy Kezelman at Inaugural Conference, Westmead Psychotherapy Program for Complex Traumatic Disorders
"Responding to the needs of consumers with complex trauma histories a consumer perspective"
Available on registration at psychevisual http://www.psychevisual.com/
, this presentation focuses on the needs of adult survivors of child abuse, highlighting the frequent failures of the current system to identify them and respond appropriately.
2016 | Working Therapeutically with Complex Trauma>>
2015 | Supporting the Wellbeing of People Experiencing a Trauma Response >>
The third in a three-part professional development series focused on complex trauma, watch this webinar to benefit from an interdisciplinary panel's insights as they discuss a case study.
Benefit from an interdisciplinary panel's insights as they discuss a case study. Panelists are Ms Jac Taylor (SA based Coordinator Counselling Services & Royal Commission Support Services); Ms Naomi Halpern (VIC based social worker); Mr John Ellis (NSW based survivor/solicitor providing legal support to survivors); Adjunct Prof Warwick Middleton (QLD based psychiatrist)
2014 | Recognising, Screening and Assessing Complex Trauma >>
Recognising, screening and assessing complex trauma Dr. Mary Emeleus moderates this webinar, the second in a series of 3 delivered by MHPN, supported by ASCA and funded by Royal Commission Support Services Initiative. Panellists are Dr Johanna Lynch (QLD based GP); Ms Michelle Everett (NSW based clinical psychologist); Mr Dragan Wright (NSW based consumer advocate); Adjunct Prof Warwick Middleton (QLD based psychiatrist)
2014 | Recognising and Responding to Complex Trauma >>
Dr. Mary Emeleus, GP moderates this MHPN webinar which was supported by ASCA and delivered to a GP audience. Panellists are Prof Louise Newman, psychiatrist; Dr. David Walker, GP; Iggy Kim, mental health nurse; Dr. Cathy Kezelman, consumer advocate, President of ASCA.
2013 | A Collaborative Approach to Supporting Adult Survivors of Childhood Abuse >>
Mary Emeleus, GP moderator with panelists, Dr. Cathy Kezelman, ASCA President; Johann Lynch GP and member of ASCA Advisory Panel, Dr. Richard Benjamin, psychiatrist and member of ASCA Advisory Panel, Mr. Philip Hilder, psychologist.
2011 | Complex Trauma, working together, working better to support adult survivors of childhood abuse >>
Participants: Prof Warwick Middleton, ASCA Advisory Panel, Dr. Cathy Kezelman, ASCA President, and Ursula Benstead, a psychologist from Melbourne.Moderated by Dr. Michael Murray GP and medical educator.
Facilitating Transition after Child Sexual Abuse >>
This resource was developed by the Royal District Nursing Service SA for providers. We thank them for their generosity in making this resource available.
Reframing Responses Stage Two >>
Supporting Women Survivors of Child Abuse An Information Resource Guide and Workbook for Community Managed Organisations
2010 | Position Paper: Traumatic Amnesia ASCA & MHCC >>
Adults Surviving Child Abuse (ASCA) and the NSW Mental Health Coordinating Council (MHCC) have developed this brief literature review - Traumatic Amnesia, in response to the recent media coverage relating to the issue.Our objective is to inform Governments, health care professionals and agencies, the media and the community of the extensive research evidence which is available around Traumatic Amnesia (also referred to as Recovered Memory). Our aim is to dispel the pervasive mythology that surrounds the subject and is widely perpetuated in the media, and bring clarity a very complex controversial issue.
"Use and Abuse" | The Experiences of Adult Survivors of Child Abuse in Drug and Alcohol Treatment >>
Over the last two years ASCA has worked in partnership with the Centre for Gender Related Violence studies (CGRVS) at the University of New South Wales. The research team interviewed clients of alcohol and drug services, as well as alcohol and drug workers, about the complex relationship between childhood abuse, alcohol and drug use and mental health.This is the first time that the experiences of alcohol and drug clients with abuse histories have been documented and analysed through qualitative research in Australia, alongside the accounts of alcohol and drug workers.
Literature Review on Trauma Informed Care in Mental Health Services >>
Alexander, P., & Anderson, C. (1994). An attachment approach to psychotherapy with the incest survivor Psychotherapy: Theory, Research, Practice, Training, 31(4), 665-675.
Amir, G. & Lev-Wiesel, R. (2007). Dissociation as depicted in the traumatic event drawings of child sexual abuse survivors: A preliminary study The Arts in Psychotherapy 34, 114-123.
Amir, N., Stafford, J., Freshman, M., & Foa, E. (1998). Relationship Between Trauma Narrative and Trauma Pathology Journal of Traumatic Stress 11(2), 385-392.
Andrews, G., Gould, B., & Corry, J. (2002). Child Sexual Abuse Revisited. Medical Journal of Australia, 176, 458-459.
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