The Therapeutic Relationship As The Foundation for Treatment with Adult Survivors of Sexual Abuse
Abstract: Survivors of sexual abuse enter psychotherapy with special needs that challenge some of the traditional therapeutic assumptions. The therapeutic relationship, which is the foundation for treatment with abuse survivors, often must shift in nature and quality to address these needs. The main goal of treatment is the integration of self and affective experience. To facilitate this process the authors discuss the establishment and maintenance of an "affective edge" which allows for direct attention to and intervention with the trauma memories and the accompanying affect.
The violations of children's bodies, especially by people in positions of affection and authority, create deeply held difficulties with trust, intimacy, and dependency. This traumatization causes profound vulnerability and vigilance which continue into adulthood. To deal with these overwhelming experiences, victims of childhood abuse numb their bodies and disconnect from the existence, impact and/or meaning of their histories.
Traditionally, psychotherapy has focused primarily on personality structure and the resulting disturbances in the individual's system of thoughts, emotions and beliefs. However, in recent years clinicians have also begun to develop an understanding of the repercussions of physical threats, intimidation, and violence, as it has become increasingly necessary to treat the impact of wounds to the body as well as the mind.
During treatment with adult survivors, directly addressing the painful memories of childhood and the accompanying affect is essential for the resolution of sexual abuse (Cornell & Olio, 1991). As Wilson (1989) explains, "the successful working through of distressing affect and imagery restores a sense of integration, coherence, and cohesion to a previously fragmented self" (p. 203).
The authors advocate the development of an active, affective, therapeutic relationship to create a safe, interactive environment. This type of therapeutic relationship provides the context necessary for accessing, reworking, and integrating the traumatic material. It becomes the foundation for treatment; acting as a bridge to facilitate the survivor's reconnection to self and offering a corrective interpersonal experience. Providing, sustaining, and monitoring this type of therapeutic relationship is emotionally demanding and involves unusual challenges and responsibilities for the therapist.
Growing Understanding of Sexual Abuse
Both the awareness and understanding of childhood sexual abuse and its consequences, as well as the development of models for effective therapeutic intervention are relatively new and rapidly expanding. In the mid-1960s, Kempe and colleagues reported (Kempe et al., 1962) on the "battered child syndrome" and the subsequent institution of child abuse reporting laws initiated a dramatic change in our awareness of childhood physical and sexual abuse. Developments in the legal and social service systems were followed in the 1970s by a convergence of the child-protection and women's movements. As a result of these groups' common interest, child sexual abuse began to attract widespread professional and media attention which resulted in dramatically increasing numbers of research projects into the troubling questions of sexual abuse (Meiselman, 1990).
Many investigations reflected a change in focus from the extrafamilial offender to the familial offender, usually the father or stepfather (Haugaard & Reppucci, 1988). With this shift, investigators began to examine the family system, focusing on the dynamics within the abusing family rather than concentrating on the individual characteristics of the perpetrator (Herman, 1981; Justice & Justice, 1979; Meiselman, 1978; Swanson & Biaggio, 1985). This focus on family dynamics produced a deepened understanding of the interpersonal damage caused by sexual abuse (Gelinas, 1983; Tsai & Wagner, 1978), highlighted the pervasive use of denial within the abusing family (Courtois, 1988) and the victim's resulting feelings of self-doubt and self-blame (Finkelhor, 1978).
Numerous efforts were made systematically to determine the prevalence of childhood sexual abuse. Although the rate of abuse varies from study to study, some researchers found instances of sexual abuse to be as high as 1 in 10 for boys (Finkelhor, 1979) and 1 in 3 for girls (Russell, 1983). As the widespread prevalence of child sexual abuse became more apparent, professionals began to ask questions regarding differential diagnosis (Ellenson, 1985), memory loss (Swanson & Biaggio, 1985), and the lack of self-disclosure (Butler, 1978; Lister, 1982).
The long-term consequences of sexual abuse became the focus of extensive inquiry (Gelinas, 1983; Herman, Russell & Trocki, 1986; Meiselman, 1978; Starr & Wolfe, 1991). Studies indicate that adult survivors of sexual abuse display higher incidences of depression, often accompanied by suicidal ideation (Briere & Runtz, 1986; Herman, 1981), sexual dysfunction (Meiselman, 1978; Sprei & Courtois, 1988), difficulties with trust and intimate relationships (Courtois, 1979; Herman & Hirschman, 1977), and self-medication with drugs and alcohol (Peters, 1988). These individuals are also at a higher risk for revictimization (Finkelhor & Browne, 1985; Russell, 1989).
The vast majority of this clinical research focused on women as the victims of sexual abuse. In the last few years, however, professionals have also begun to examine the experiences of men who have been sexually abused (Bolton, Morris & MacEachron, 1989; Bruckner & Johnson, 1987; Dimcock, 1988; Grubman-Black, 1990). As a result, childhood sexual abuse is increasingly being viewed as a misuse of power (Gelles & Straus, 1988) which is committed by both men and women upon victims of either sex.
Despite overwhelming documentation of the long-lasting consequences produced by childhood abuse, the role trauma plays in causing this damage, and the resulting implications for treatment, have been contested. The last fifteen years have seen a growing theoretical and technical understanding of Post-Traumatic Stress Disorder (Horowitz, 1976; Ochberg, 1988) which views the symptoms characteristic of abuse survivors as normal, expectable adaptations to extremely stressful life events. Much of the contemporary literature on PTSD therapy (Ochberg, 1991; Wilson, 1989) and the treatment of adult survivors of childhood abuse (Brickman, 1984; Courtois, 1988; Miller, 1984) criticizes the traditional, psychoanalytically derived perspective which de-emphasizes the reality of childhood trauma memories and emphasizes instead instinctual wishes and conflicts, fantasy and preexisting deficits in personality structure.
This controversy has had a major impact on clinicians of varied approaches regarding their conceptualization of treatment for victims of childhood trauma. Current psychoanalytic literature (Bollas, 1989; Grotstein, 1990; Levine, 1990; Kramer & Akhtar, 1991; Shengold, 1989) reflects a shift toward an increased recognition of the realities of childhood sexual and physical abuse and the impact such bodily trauma has on intrapsychic and interpersonal functioning in adult life. In addition, there is an increased emphasis on the role of the analyst in facilitating reality testing through validation of the actuality of the abuse (Kramer, 1990). As Chu (1991) states, "It is only with the recognition of the presence of old trauma and the acknowledgment of the importance of trauma in producing emotional disturbance and psychiatric illness that these patients can be effectively treated" (p. 331). This controversy has also resulted in a critique of the narrowness and dynamic shallowness of trauma-focused approaches. These "incest resolution therapies" (Haaken & Sclapps, 1991) have been described as oversimplified, in that they provide validation and normalization of the client's responses to the trauma, but fail to give adequate attention to the aggressive, self-destructive and transferential aspects of a client's functioning.
Recent efforts have begun to integrate both concerns. Bernstein (1990) suggests that "we must find a proper balance between the need to provide a reparative, caretaking relationship and the temptation to forsake the analytic stance for a supportive one" (p. 90). McCann & Perlman (1990) describe a theoretical model and treatment approach that integrates a self-psychological framework with trauma-centered treatment, dealing actively with both post-traumatic symptomology and transferential and characterological issues.
Special Treatment Considerations
There is great diversity in the adult life difficulties of survivors of childhood abuse. These individuals demonstrate widely varied temperament styles, character defenses, and developmental disruptions. As Steele (1990) noted, "the sexual events do not occur as isolated events in an otherwise 'good enough' environment; they are typically the more dramatic and traumatic episodes in an otherwise chaotic, depriving milieu of inadequate, distorted caregiving" (p. 32). Depending on the family's characteristics, other resources available to the child, and the child's temperament, survivors develop differing character defenses to cope with the chronic dysfunctions within the abusing family.
Kris (1956) and Pine (1990) differentiate between this "strain" trauma—chronic, repeated, disturbing experiences which foster developmental and characterological distortions—and "shock" traumas, which are sudden, overwhelming, invasive experiences. These shock traumas, which include physical and sexual abuse, are at the heart of a specific pattern of symptoms and defenses characteristic of PTSD. Although the impact may vary, intrusions and assaults on children's bodies create specific types of damage that in some degree are common to all survivors, regardless of their individual differences in character style. Because of the unique difficulties caused by shock trauma, adult survivors of childhood abuse have special needs which must be specifically addressed in the therapeutic process.
Use of Denial and Dissociation
Children who are abused encounter confusing, frightening, painful, and sometimes life-threatening experiences. In order to survive such emotionally overwhelming and physically overstimulating experiences, these children use denial and dissociation as primary psychological coping strategies.
Rieker & Carmen (1986) describe denial as the process that occurs when "the victim's feeling 'this can't be happening to me' becomes 'this didn't happen to me'" (p. 365). The use of denial by survivors ranges from denying the actual occurrence of the abuse to denying its impact and its relevance to difficulties in the individual's current life.
Patterns of denial originate in the family system where denial is often used prior to any instances of abuse as a common coping strategy to deal with problems which cause conflict and discomfort (Courtois, 1988). These patterns of denial, which are systematically maintained by the abusing family, are internalized by the abused child and may continue to be used throughout adult life.
The manifestations of denial among survivors are remarkably similar, but the functions differ from individual to individual, reflecting idiosyncratic meaning which must be directly addressed. For each victim there are specific aspects of the abuse (loss of family, loss of the only person who "loved" them, hopelessness and despair, etc.) that seem particularly unendurable. Denial assists in the maintenance everyday functioning by providing a means of self-protection from these deeply disturbing experiences.
As a result of the pervasive use of denial, survivors of sexual abuse suffer from intense, persistent self-doubt, often thinking that they have "made up the memories," are "exaggerating," or being "hysterical." This creates special difficulties for treatment as survivors repeatedly minimize, disavow and disconnect from their own experiences. The therapist must help the client to identify these patterns of denial and reconnect them to their origins within the family system as well as clarifying and directly addressing their continuing functions in current life. If the therapist only attends to the defensive function of denial without addressing the underlying damage caused by the abuse, the client may again feel violated. In the face of the continued re-emergence of the client's self-doubt and confusion it is important for the therapist to hold the centrality and significance of the abuse experiences. However, focusing only on the historical damage, without exploring the client's current defensive styles, leaves the therapy incomplete.
Research in the area of PTSD (Figley, 1985; Horowitz, 1976; Wilson, 1989) has enhanced our understanding of the role dissociation plays in the management of trauma. In health, the mind integrates consciousness (i.e. awareness, affect, cognition, identity, and behavior) into unified and coherent experiences. With the use of dissociation, one or more of these elements is split off from consciousness, resulting in a fragmentation of self and/or experience. Lifton (1979) describes the dissociative process as one in which "the self is being severed from its own history, from the grounding in such psychic forms as compassion for others, communal involvement, and other primary values" (p. 175).
The use of dissociation follows a continuum ranging from abrupt, momentary disruptions to chronic impairment of consciousness and identity. It is likely to occur first during the actual abuse, to protect the victim against the overwhelming experience of trauma as it is being inflicted, and then again later to defend against the memory and affect of the experience (Spiegel, 1986a). During the abuse, the use of dissociation enables children to anesthetize parts of their bodies and/or separate from them altogether, thus disconnecting themselves from the emotion and sensations of the abuse. This pervasive tendency to disconnect from feeling continues into adult life, frequently disrupting affective and body experiences and impeding the survivors' ability to bring a felt sense of their history into the treatment process.
The primary goal of the treatment process, therefore, must be to facilitate an integration of the trauma experiences. As Wilson (1989) notes, "to heal from the emotional effects of trauma involves the reestablishment of continuity and cohesion in the self which integrates the core processes of the person" (p. 196). The therapist must help survivors to identify their use of the dissociative process and offer sufficient emotional grounding to facilitate the integration process.
Lack of Disclosure and Memory Loss
It is common for survivors to delay or sometimes omit disclosure of their abuse histories. This creates unique difficulties as treatment requires direct attention to the issues of abuse and cannot effectively proceed without correct identification of the source of the difficulties. Failure to disclose stems from a number of diverse factors.
Victims of sexual abuse are often told to "keep it a secret." Frequently, if they do reveal the abuse, they are called crazy, liars, or troublemakers, and told to forget about it. Given that most perpetrators deny responsibility for their behavior and discount the hurt and upset caused by it, victims often feel ashamed, believing that they were in some way responsible for the abuse.
Such factors make survivors of sexual abuse particularly sensitive to any indications of disbelief, avoidance, or lack of follow-up on the indications of abuse by the therapist. Thus, the therapist's willingness to consider the possibility and significance of abuse is of primary importance (Butler, 1978; Herman, 1981). A serious response from the therapist, addressing possible indications of abuse and inviting further exploration is necessary. Direct, matter-of-fact inquiry and follow-up regarding violence or sexual abuse in childhood enhances the likelihood of self-disclosure.
At 42, John described his experience: "I entered therapy at 27 and have been working off and on most of those years with five different therapists. I had some concrete memories of 'what happened' for years, but never dealt with them in therapy because I was 'too ashamed' and because 'I feared that I might have wanted it to happen.' None of the therapists ever asked me about sexual abuse as a possibility, and I never revealed the memories I did have access to."
Survivors sometimes cope with abuse by "putting it behind them" and thus are unaware that their current life difficulties are connected to the childhood trauma. Therapists may miss or underestimate the relevance of the abuse experiences as victims may report these incidences without apparent distress. Typically, this lack of affect reflects the victims' life-long pattern of using denial and dissociation rather than the absence of damage or a successful resolution of the childhood trauma.
In a surprisingly high number of instances, the lack of disclosure is due to the survivor's partial or total loss of the trauma memories (Blake-White & Kline, 1985). Together, denial and dissociation comprise a tenacious coping strategy. It is easier to deny an experience that one does not feel. Thus the survivor becomes "numb and dumb," as parts of or entire abuse experiences are lost from conscious awareness. This process not only accounts for the loss of the original memory but also may cause sporadic memory loss in adult life (Olio, 1989). These difficulties underscore the critical need for the therapeutic relationship to provide inquiry, follow-up, and validation.
Flashbacks and Regression
Flashback experiences in one form or another are almost universal among abuse victims (Ellenson, 1986). They involve a wide variety of sensory experiences, including physical sensation, visual images, and auditory phenomena. These experiences often frighten survivors who may fear they are "going crazy." These flashbacks are not hallucinations; rather, they are memory fragments that have emerged in response to some trigger that often is out of the abuse survivor's awareness.
Because of the dissociative process, flashbacks and the retrieval of traumatic memories are often experienced by the survivor as a movie that was stopped in mid-frame and then unexpectedly restarted years later. The client does not just remember the abuse; he or she literally re-experiences the childhood trauma (Spiegel, 1986b).
During the session, as Nancy described her abuse history, she spontaneously regressed. Her facial features and body posture looked like a small, frightened child. She began crying hysterically. When asked what was wrong, she reported having recurrent images of a bathroom.
It becomes the therapist's responsibility to provide containment, structure, and support to facilitate the processing of the fragmented images, affect, and the regressive elements that surface as the survivor reexperiences the abuse during the integration process.
The Therapeutic Relationship
Regardless of clinician's differing technical approaches to therapy, the quality of the therapeutic relationship is of singular importance in treatment with victims of sexual abuse. The relationship with the therapist must be the foundation of the therapeutic process with survivors, as it provides the context in which the traumatic memories and accompanying affect can be addressed. This relationship must address both transferential material and offer a realistic, present-day relationship. It serves two functions—facilitating the survivor's integration of self and offering a corrective experience for the interpersonal damage to trust, dependency, and intimacy.
Addressing both these functions, crucial for effective treatment with survivors, presents special challenges. Increased sensitivity to issues involved in the resolution of sexual abuse experiences alone is not usually sufficient. Rather, alterations in the nature and structure of the therapeutic relationship, which include an increased emotional availability and responsiveness by the therapist as well as a greater responsibility for holding the literal and emotional content of the therapy, are often required.
The transferential expectations victims may bring to the therapeutic process, which include failure to protect, abandonment, indifference and even assault, can be intensified by the therapist's silence and passivity (Rose, 1991). A neutral stance, appropriate for some types of clients, is not effective and can even be harmful for adult survivors. As Spiegel (1986b) explains, "traditional analytic reserve is often perceived by the patient as a lack of concern or even a sadistic pleasure in the patient's suffering" (p. 72). Attitudes of "distance" or "therapeutic neutrality" are likely to remind abuse victims of their dysfunctional family's patterns of interaction and therefore reinforce the patterns of denial. A similar recreation of the abusing family's attitudes can also result from instances where the therapist manages the intense countertransference reactions to these client's painful experiences, by distancing from or minimizing the significance of the abuse.
The therapist, therefore, must abandon traditional reserve and shift to a stance of "active engagement" (Olio, 1989). This stance offers explicit, repeated invitations for contact between the therapist and client, followed by observation and inquiry regarding the meaning to and impact on the client. Active engagement reflects the balance of sufficient initiation by the therapist, to create a responsive environment without reaching a level or intensity of intervention which becomes intrusive or controlling. If the therapist holds back, out of fear of intrusion, he or she may fail to provide the level of contact and emotional involvement necessary to encourage disclosure and access to the traumatic memories and accompanying affect.
Several sessions ago Jane spoke, with difficulty, about a memory of being abused by her brother. Her therapist, wanting to respect her pace, decided not to refer to it again, waiting for Jane to bring it up when she was ready. Jane broke the family "rules" by telling. Afterward she felt frightened and thought she had done something wrong. When her therapist failed to mention the memory, she began to think that she had been exaggerating and that the incident wasn't such a big deal.
This shift can often be difficult for clinicians who have been trained to view neutrality and therapeutic distance as a valuable asset and who may fear creating an overly involved or overly intrusive environment. While a significant level of emotional involvement is an essential ingredient in the therapeutic relationship with victims of childhood abuse, over-involvement on the part of the therapist must be monitored as well. Active engagement requires the therapist's willingness to initiate interaction with, and attune, to each survivor. The therapist must engage in an active process to develop a relationship that fits the particular individual's needs, rather than one which simply reflects the therapist's assumptions of the "correct way to proceed." This stance includes the therapist's responsibility to inquire about the client's internal experience as well as monitoring the quality of his or her everyday life.
In order to facilitate the client's reconnection to self, the therapeutic relationship must offer both containment and bridging. Throughout the treatment process, and especially in the face of previously repressed memories and the powerful affect and ego disorganization that accompany them, the therapeutic relationship needs literally and symbolically to provide a containment or holding environment for the client. During these periods the therapeutic work must foster active support and interaction that responds to the client's regressive needs.
As Susan was returning home from her therapy session she saw an older man walking in the street. She began to have intrusive images followed by a panic attack. She called her therapist, and at his suggestion wrote me images. He told Susan to seal them in an envelope and mail it to him to keep until her next session. After mailing the letter Susan was able to return to her daily routine.
The fragmentation resulting from the use of denial and dissociation creates other difficulties in the treatment process. The client's ability simultaneously to retain both a cognitive account and a felt sense of the abuse experiences can vary not only from moment to moment within the session, but also from session to session and from one context to another. Through consistent attention and follow up, the therapist temporarily becomes the bridge between the pieces of self and experience that the client has split off, gently and persistently holding the reality of the traumatic experiences throughout the client's confusion, self-doubt, and forgetting.
The therapeutic relationship must also address the repair of the interpersonal damage survivors suffer as a result of the childhood traumas (Kaufmann, 1985). Trusting relationships with others are diminished by both the frequent use of coercion that is typical in abusive families and by the violation caused by the abuse itself (Briere & Runtz, 1986; Timmons-Mitchell & Gardner, 1991). A major goal of treatment, as Catherall (1991) notes, is "the re-establishment of a trusting relationship between the victim and his or her most immediate experience of the human community, the therapist" (p. 145). The re-establishment of trusting relationships requires this issue to be addressed explicitly and repeatedly over time as the client and therapist actively engage in a relational process that counters the client's early experience of coercion and betrayal in primary relationships. The therapeutic relationship must withstand and remain constant in the face of conflict, disappointment, disillusionment, the projections and demands of transference and counter-transference reactions, and often profound ambivalence to both the therapeutic process and relationship.
The role of the therapist's own feelings takes on a special importance as families of adult survivors often responded to the abuse with blindness, silence, or discounting. The experience of the therapist's normal, human emotion in response to the trauma can become an important part of repairing the interpersonal damage as it demonstrates that what happened to the survivor matters and is significant to someone. This expression of emotion by the therapist, however, challenges traditional notions of therapeutic boundaries, and must be accomplished in such a way that the therapist's needs and emotions to not become the focus of the therapeutic process.
Sympathy and good intentions alone are not sufficient and cannot substitute for clinical understanding and effective intervention in treatment with survivors of childhood abuse. However, respect and kindness are important ingredients of the therapeutic relationship as these attitudes facilitate important corrective functions in treatment. These are qualities that are singularly lacking in abusive families. Often, even well-planned and technically correct interventions will be ineffective unless they are executed within the context of a therapeutic relationship that conveys kindness and respect.
The paradigm of "learned helplessness" (Seligman, 1975) has been used in some instances (Flannery, 1987; Walker, 1989) to understand both the feelings of depression, helplessness, and low self-esteem, as well as the increased risk of revictimization, which often persist long after incidences of childhood abuse. More recently, in an effort to understand why abusive experiences are not equally traumatic to all individuals, a more complex analysis has been suggested which considers differences in an individual's value systems, availability of support figures and the resources of the community at large (Flannery & Harvey, 1991; Koss & Harvey, 1991).
These authors would argue that it is not so much learned helplessness that determines the impact of the trauma on individuals, but rather, "learned hopelessness." Individuals are often resilient in situations where they experience helplessness so long as they can maintain hope that the situation will improve (Frankl, 1959). The elements articulated by Koss & Harvey (1991) are significant factors which affect the degree to which an individual experiences hopelessness. In the therapeutic process with abuse victims who, as vulnerable children, suffered unendurable experiences, providing hope becomes an important task. As Browne (1991) explains, "if a pathway to improvement appears to be non-existent, victims stop talking. … Disclosure without a positive response often results … in an increased sense of helplessness and vulnerability." (p. 150)
Use of Touch
The intentional use of touch by the therapist is a controversial and sensitive issue in psychotherapy. This is especially true in working with survivors of childhood abuse whose history of touch is a negative one in which touch has been sexualized, intrusive, and in some instances assaultive. Although it is not essential that the therapist directly touch a client in order to attend to or alter the emotional processes that emerge in treatment, the skillful use of direct physical contact with victims of sexual abuse can, in many instances, offer a powerful treatment intervention.
The appropriate use of touch, within the context of an ongoing therapeutic relationship, can offer contact, provide nurturing, convey safety, and encourage increased self-awareness. Physical contact can facilitate a deepening of the client's affective experience and provide a connection to the trauma experiences that may be difficult to achieve with words alone. Within the context of the therapeutic relationship, the client can experience respectful, engaging touch in sharp contrast to the abusive, uncontrollable touch associated with the original trauma.
Touch used as a therapeutic intervention covers a wide spectrum of techniques. Therefore, the question of which uses of touch are most effective in the treatment of abuse victims becomes an important one. While numerous specialized therapies (Boadella, 1987; Lowen, 1975; Reich, 1961) offer approaches which are body-centered and use therapeutic touch as a matter of course, more conventional psychotherapies provide no systematic approach for the use of touch by the therapist. Goodman & Teicher (1988), however, suggest a useful characterization of therapeutic touch based upon its intent, as being either holding or provoking. "Soft" body-centered techniques (Smith, 1985), such as supportive touch, calling attention to posture and sensations in specific areas of the body, deepened breathing, and eye contact, fall within the first category of "holding" touch. These forms of touch heighten self-awareness and, when used as an extension of the therapeutic relationship, are the most appropriate for survivors.
Other touch/body-centered techniques that are intended for mobilizing or provoking tend to focus on expression and are often overly stimulating and too intrusive for survivors, and can cause a replay of the original trauma (Cornell & Olio, 1991). The use of therapeutic touch is not appropriate for all clients, and each case must be individually evaluated. Any use of touch, of course, must be mutually agreed upon as part of a broader treatment contract that supports the client's prerogative to reconsider and/or decline the use of touch at any point.
The management and integration of affect, both within the process of remembering the traumatic experiences as well as in current life, is crucial in the resolution of childhood abuse. Chronic use of denial and dissociation by abuse survivors often results in emotional flatness, disconnectedness, and/or emotional fragmentation. An intensity of affect or an utter lack of affect may accompany the client's remembering and disclosing of abuse experiences. Victims of sexual abuse may periodically experience episodes of intense affect, which are spontaneously triggered by external life situations. The emergence of strong, sometimes uncontrollable, affect can be deeply disconcerting to both the client and the therapist (Wilson, 1989).
These symptoms, which are consistent with PTSD, may be mistaken for decompensation (Gelinas, 1983) and result in a therapeutic decision to discontinue direct work at an affective level. In response to this intense affect, clinicians have occasionally erred in the opposite direction, encouraging abreaction through the use of interventions that focus on expression and catharsis rather than self-connectedness. Interventions geared primarily toward affective expression and catharsis are both overly stimulating and too intrusive. The use of such techniques may produce dramatic-looking sessions, but can leave clients without an internal connection to the displayed emotion and/or its content. All too frequently, the result of such interventions is an increase in the abuse victim's confusion, memory loss, anxiety, and/or depression.
Elizabeth described a previous therapy experience: "I desired the intensity and catharsis. However, contradicting my own assumptions about therapy, no number of catharses seemed to make any difference in my depression or my increasing anxiety with my therapist. Instead of healing the abuse through the transference, we were perpetuating it."
Attempts to manage the intensity produced by these overstimulating interventions usually result in the client's increased need to use denial and dissociation. This can cause sudden and marked changes in the therapeutic relationship, as the client may become increasingly compliant or may begin to distance in the face of the overly stimulating and intrusive techniques.
The therapist must directly encourage the clients' gradual acceptance and deepening of affect to facilitate the integration of the abuse experiences. This includes both the affect resulting directly from the abuse and that which is a reaction to the environment's failure to protect and comfort. This affect must be reconnected to the content of the trauma in order for the survivor to make meaning of their experiences.
This integration process requires the establishment of an "affective edge." These authors describe this edge as the range of experience within which the client is able to sufficiently move out of denial to experience a felt awareness of the abusive experiences and their consequences, without reaching the level of intensity that would trigger dissociation (Cornell & Olio, 1991). Working at the affective edge provides an avenue for accessing affect and deepening the client's connection to self and personal history, thus permitting reworking of traumatic material and its integration into current life.
The quality of the therapeutic relationship is crucial in establishing and maintaining the affective edge. The therapist's direct stance and attitude facilitates an interruption in the client's use of denial, intensifies emotional contact allowing access to the traumatic material and offers containment which facilitates the client's increasing tolerance of the affect. In order to maintain the affective edge, the therapist must recognize the client's re-emerging use of denial and/or dissociation and moderate the intensity and pace of treatment accordingly. When the affective edge is exceeded denial and/or dissociation reemerge interrupting the integration of the trauma material resulting in a loss of the therapeutic opportunity. In such instances the treatment must be slowed. Until the client's connection to self can be re-established, the therapist literally becomes the living record of the therapy by maintaining the reality of, and appropriate affect related to, the sexual abuse.
Integrating Trauma Memories
Recovering memories of the childhood trauma is not an end in itself. However, for the survivor of sexual abuse, such memories are a crucial part of reconstructing and reconnecting to one's own personal history. Despite the defensive forces of denial and dissociation, there is, as Chu (1991) describes, "an opposing need on the part of the psyche to force repressed material into consciousness" which can take on an "almost biological urgency" (p. 328). The importance of reliving these memories is not primarily for catharsis, but for the assimilation of these experiences (Herman & Schatzow, 1987).
Accuracy of Traumatic Memories
Contrary to the popular belief that memory functions like a camera, recording and storing an entire experience for recall at some later date, memory actually is continuously and permanently being altered by an ongoing process of updating with subsequent events, changes in perceptions, external feedback, and even internal speculation (Loftus & Loftus, 1976, 1980; Wells & Loftus, 1984). Consequently, a client's memory of childhood abuse may contain ideas and fragments derived from later perceptions and experiences.
Accuracy may also be affected as different events are not necessarily stored in memory as separate occurrences. Similar but distinctly separate events may be combined into a condensed version of reality (Neisser, 1981). This condensation can lead to confusion when a survivor of abuse tries to reconstruct specific instances of the trauma. The traumatic memory may include details from a number of different places, ages, and in some instances different people which are combined into a single scenario.
In addition to the impediments inherent in any memory retrieval process, victims of childhood abuse may have additional difficulties as a result of the trauma experiences. Terr (1991) describes the amnesia and fragmentation that result from the repetitive, intrusive trauma that is typical in abusive families. By way of contrast, the details of "single-blow" trauma are frequently remembered in vivid and coherent detail.
Although these factors highlight the inevitable inaccuracies present in the details of traumatic memories, they do not suggest or offer any indication that memories and/or accompanying affect related to childhood trauma are constructed and remembered in instances where no abuse occurred. The existence of inaccuracies therefore, does not invalidate the essential truth of what is recalled. With survivors of childhood abuse the inaccuracies and confusion concerning the details of the trauma in no way diminish the reality of the abuse itself.
Retrieval of Traumatic Memories
The ability of an individual to gain access to trauma memories is primarily determined by three factors. Perhaps the most significant factor is the individual's current ability to tolerate the particular content or meaning of the abuse, an experience so unendurable in childhood that it precipitated the original memory loss. Often the client's tolerance level significantly increases as safety and consistency are established in the context of the therapeutic relationship.
A second factor, the lowering or softening of the individual's defenses (Courtois, 1990), also increases access to trauma memories. This softening may occur as the result of deliberate efforts in the therapy process or spontaneously as the result of a life crisis, changes in life style (sobriety, weight loss, etc.) or from relaxation, illness or exhaustion.
Finally, a third factor which facilitates memory retrieval is the presence of external "triggers" (Olio, 1989). A variety of stimuli can serve as triggers. It could be a current instance of revictimization or a developmental event such as the birth of a child, a child's reaching the age of the parent's victimization, a child's leaving home, etc. Or the trigger could simply be any change which increases the emotional intensity of life. This can be either a negative event, such as a disappointment, failure, or loss, or a positive change, such as a career success, falling in love, etc. Sometimes trauma memories are triggered by medical or dental procedures. In other instances, previously neutral stimuli which resemble some aspect of the abuse, or the disclosure of others (family, friends, group members, media accounts) can also trigger memories.
The use of triggers to facilitate the return of traumatic memories is highlighted by an understanding of the distinction between two different retrieval processes—recognition and recall. Recognition is a simple, one-step process in which the individual determines if an externally provided stimulus is familiar. Recall, a more complex, two-step process, requires the individual to generate a possibility and then determine if it is familiar.
Denial and dissociation inhibit the consideration of abuse, thus reducing the likelihood that survivors' will internally generate the possibilities required to initiate the recall process. The recognition process, which utilizes external cues, provides greater access to the trauma memories. As Anderson (1980) observes, "we can recognize many things we can't recall … recognition often works even when recall fails" (p. 121). During the therapy process, the therapist may wish to utilize specific therapeutic modalities (e.g., hypnotherapy, dream analysis, body-centered interventions, and group treatment) that will maximize the availability of these triggers.
A personally reconstructed history, with its' primary focus on the meaning to the individual rather than the on the literal facts, is sufficient for addressing most issues during treatment. However, because of the years of silence, the family denial, and the victim's own disconnection from personal history, in the therapeutic effort to resolve abuse, the question "Did this really happen?" is of critical importance. Therapeutic validation requires an acknowledgement of the abuse as an external reality.
No therapeutic process can ever reconstruct childhood in absolute, literal detail. However, in the treatment of adult survivors it is crucial for the client to reconstruct as clearly as possible, a "picture" of the abusive events and the context which enabled them to occur. What happened and how it happened needs to be uncovered, understood and felt. Despite the inaccuracies and distortions inherent in all memory retrieval, the trauma memories need to be recovered and re-experienced with appropriate affect. The therapist must continually acknowledge the reality of the abuse for the trauma memories to continue to unfold and for the survivor's trust in his or her perceptions to be restored.
The past twenty years have seen dramatic changes in the awareness and understanding of the long-lasting effects of childhood sexual abuse. Survivors of abuse, who as children suffered at the hands of people in positions of love and authority, enter psychotherapy, as adults, with special needs. Childhood abuse often results in emotional numbness and disconnection, diminished vitality, and a fragmented sense of self. Victims of abuse continuing patterns of denial and dissociation into adult life can results in partial or total memory loss of both the traumatic events and important segments of their histories. Frequently survivors are left doubting their own reality. Addressing these issues often requires a shift in the nature and structure of the therapeutic relationship.
The authors advocate the development of an active, affective, therapeutic relationship, as the foundation for treatment. Such a relationship creates a safe and responsive environment which allows for accessing, reworking, and integrating the traumatic material. It provides a vehicle to facilitate both the client's reintegration of self and the re-establishment of trustworthy relationships with others. This article offers a conceptual framework within this relational context for direct attention to and intervention with the trauma memories and the accompanying affect.
The integration of sexual abuse into adult life requires survivors to fully acknowledge the painful reality of their childhoods and the resulting damage done to them. They must re-own their feelings of helplessness, fear, desperation, and rage without splitting off parts off themselves to tolerate these feelings. The goal of the therapeutic process, then, is not primarily "overcoming the past" or expression and catharsis regarding the past, but rather one of encouraging emotional vitality and personal integration. If the therapeutic relationship can provide enough safety, containment and emotional contact, survivors can transform their experiences of abuse. They can regain a sense of empowerment while reclaiming all the parts of themselves and their experiences.
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