Treating Adults Who Were Sexually Abused As Children: Central Principles
By John Briere, Ph.D.
NCP Clinical Quarterly 6(2): Spring 1996
Childhood sexual abuse is both common in our culture and associated with a variety of psychological symptoms and difficulties (1). A growing body of research and clinical experience suggests that the psychological treatment of abuse effects is likely to be complex, requiring specialized skills and information. At the same time, the principles of good, generic psychotherapy are directly applicable to this population. This article briefly outlines a number of central principles that are helpful with abuse-related psychological distress.
Ethical Issues
The ethical issues involved in the treatment of abuse survivors are generally the same as those for any other client population. They may be even more salient in work with abuse survivors, however, since sexual abuse can produce a variety of interpersonal difficulties, significant boundary confusion, and greater vulnerability to client-therapist dynamics. Most important to abuse-focused therapy, the client should be made aware of therapeutic confidentiality (and its limits), the therapist's duty to protect and warn, potential side effects of certain therapeutic interventions (e.g., hypnosis or medications), and the potential for treatment to temporarily exacerbate certain symptoms (e.g., posttraumatic stress or dysphoria). As well, the therapist should be aware of the limits of his or her expertise in treating abuse survivors, seeking out consultation, supervision, and/or additional training when necessary. Therapeutic interventions should be those accepted by specialists in the field, and should be appropriate to the survivor's specific difficulties.
It also critically important that the clinician be sufficiently self aware, psychologically healthy, and under sufficient self-control that he or she does not act out countertransferential issues on the client. Such issues obviously include inappropriate anger, sexual expression or behavior, and physical or psychological boundary violation.
Assessment
Because sexual abuse can produce a wide variety of symptoms and disorders, assessment is especially important when working with abuse survivors. Not only should treatment begin with a psychosocial evaluation, some form of assessment should be an ongoing component of the treatment process. Symptoms may wax and wane across treatment, or may be affected by initial levels of dissociation and other avoidance responses that decrease as treatment continues -- either of which might not be detected if assessment only occurred at the outset of therapy.
When the client is able to tolerate discussion of his or her childhood history, assessment should include a detailed evaluation of the abuse and its characteristics. The presence of other childhood and adult traumas should also be evaluated, since many sexual abuse survivors also experienced psychological abuse, emotional neglect, and physical maltreatment, and also may have been revictimized as adults. It should not be assumed that any given symptom is the result of sexual abuse, per se, as opposed to the many other potentially harmful events and processes that the survivor may have experienced.
Psychological testing can provide a rich source of information on the functioning of abuse survivors. Such tests include both generic measures (e.g., the MMPI, MCMI, Rorschach) and more abuse- or trauma-specific ones (e.g., the Trauma Symptom Inventory [2]). Both generic tests and more abuse-specific measures have strengths and weaknesses, however, that must be taken into account during interpretation (3). For example, generic tests may overlook, amplify, or distort abuse-related psychological disturbance, and yet may accurately identify comorbid symptoms or disorders, whereas some abuse-specific tests lack sufficient normative or psychometric data, and yet may provide potentially unique information on abuse-specific psychological disturbance.
Amnesia And Memory Recovery Issues
A specific issue related to the assessment of abuse and its effects is that of the validity of abuse-specific recollections. Clinicians in the field are becoming increasingly aware of the complexity of long-term recall, especially in terms of potential memory distortion effects. Given our greater understanding of the suggestibility of some survivors (e.g., those with significant dissociative symptoms), it is suggested that (a) assessment regarding abuse memories be as non-directive as is reasonably possible, such that the client is neither pressured to recall unavailable material nor discouraged from remembering what is possible to recall, (b) drug-assisted interviews and assessment-focused hypnosis be avoided when possible, or used with informed consent when absolutely necessary, and (c) amnesia neither be assumed nor prematurely ruled-out. The interested reader is referred to statements on "recovered memory" and therapy by the American Psychological Association, American Psychiatric Association, British Psychological Society, and other professional organizations for more detailed discussions, as well as to an excellent set of guidelines by Christine Courtois (4).
The Process Of Psychotherapy
Many untreated survivors of severe childhood abuse appear to spend considerable time and energy balancing trauma-related distress and intrusion with avoidance mechanisms such as dissociation, externalization, or substance abuse (5). Such avoidance, although reinforced by its immediate effectiveness in reducing dysphoria, may prevent adequate exposure to and processing of traumatic material, thereby leaving posttraumatic symptoms relatively undiminished.
Because the survivor tends to counter abuse-related dysphoria with avoidance, it is important that psychotherapy proceed slowly and carefully. A primary goal is to keep from overwhelming the client -- either by exposing him or her to unacceptable levels of posttraumatic distress, or by inappropriately discouraging needed avoidance activities (e.g., some level of dissociation). At the same time, however, the clinician must facilitate exposure to traumatic material so that it can be desensitized and integrated. As a result, effective abuse-focused interventions are neither so non-demanding as to be useless, nor so evocative or powerful that the client is retraumatized. Such interventions challenge and motivate psychological growth, accommodation, and desensitization, but do not overwhelm internal protective systems and motivate unwanted avoidance responses.
In addition to balancing challenge with stability, the clinician must work to provide a safe therapeutic environment. In the absence of continual and reliable safety and support during treatment, the survivor is unlikely to reduce his or her reliance on avoidance defenses, nor to attempt the necessary work of forming an open relationship with the psychotherapist. As well, as noted later, therapeutic safety may partially countercondition anxiety associated with the disclosure (and thus reliving) of traumatic material.
Effective therapeutic responses tend to occur on a continuum, with one end anchored in interventions devoted to greater awareness of potentially threatening but therapeutically important material (exploration), and the other constrained to interventions that support and solidify previous progress, or that provide a more secure base from which the survivor can operate without fear (consolidation).
Exploratory interventions typically invite the client to examine or re-experience material related to his or her traumatic history. For example, an exploratory intervention might involve asking the client to describe a specific abuse incident in detail, or to use slightly less dissociation when discussing a painful subject. Consolidation, on the other hand, is less concerned with exposure or processing than with safety and foundation. Such interventions involve activities than reduce arousal, "ground" the client in the "here and now," interrupt escalating internal states, and increase internal stability. The decision to explore or consolidate at any given moment reflects the therapist's assessment of which direction the client's balance between stresses and resources is tilting. The overwhelmed client, for example, typically requires less exploration and more consolidation, whereas the stable client may benefit most from the opposite.
Increasing Self Functions
Implicit in this therapeutic model is the importance of internal (or "self") capacities during trauma processing. In the absence of sufficient affect regulation skills, for example, even very small amounts of distress or dysphoria will be experienced as overwhelming and thereby motivate avoidance or externalization. So important are self resources to effective therapeutic intervention that some clients may require extensive "self work" before any significant trauma-focused interventions can occur (6).
Although a number of self capacities and functions have been hypothesized (6), perhaps most important to the successful processing of traumatic material are the related concepts of affect tolerance and affect modulation. Affect tolerance refers to the relative ability of the client to feel painful feeling without needing to avoid them through activities such a dissociation, externalization, substance abuse, etc. Affect modulation refers to the ability to alter or reduce painful affects, also without major reliance on avoidance. As noted above, in the absence of such skills, traumatic reexperiencing and dysphoria can easily overwhelm the client.
A programmatic approach to affect regulation is outlined by Linehan (7). She notes that distress tolerance and affect modulation are both internal behaviors that can be learned during therapy. Among the specific skills taught by Linehan's treatment model are distraction, self-soothing, and "improving the moment" (e.g., through relaxation). The survivor also learns to, for example, identify and label affect, reduce vulnerability to hyper-emotionality (i.e., through decreased stress), and develop the ability to experience emotions without judging or rejecting them.
Affect tolerance and modulation is also learned implicitly during effective therapy. Because, as outlined in the next section, trauma-focused interventions involve the repeated evocation and resolution of distressing but non-overwhelming affect, such treatment slowly teaches the survivor to become more "at home" with some level of distress, and to develop whatever skills are necessary to de-escalate moderate levels of emotional arousal. This growing ability to move in and out of strong affective states, in turn, fosters an increased sense of emotional control and reduced fear of affect.
Cognitive And Affective Processing Of Posttraumatic Stress
Assuming that the client either has sufficient self skills or that these self functions have been strengthened beforehand, the treatment of trauma symptoms is relatively straightforward. There are at least three major steps in this process, although they may recur in different orders at various points in treatment: identification of traumatic abuse-related events, gradual re-exposure to the affect and stimuli associated with a memory of the abuse, and cognitive/affective processing.
In order for traumatic material to be processed in treatment, it must be identified as such. Although this seems an obvious step, it is more difficult to implement in some cases than might be expected. The survivor's avoidance of abuse-related material may lead either to conscious reluctance to think about or speak of upsetting abuse incidents, or to less conscious dissociation of such events. Since such responses are avoidance defenses, they should not be punished or unduly confronted, nor should the survivor be pushed to access more painful material than he or she can tolerate. On the other hand, interventions focused on increasing perceived safety and/or developing better affect regulation may eventually increase the amount of distress the client can "handle," and thus decrease the need for such avoidance.
If, at some point, there is sufficient abuse material available to the treatment process, the next step in the treatment of abuse-related trauma is that of careful, graduated exposure to various aspects of the abuse memory. In this regard, the survivor is asked to recall non-overwhelming, but painful abuse-specific experiences in the context of a safe therapeutic environment. Exposure is graduated according to the intensity of the recalled abuse, with less upsetting memories being recalled, verbalized, and desensitized before more upsetting ones are considered. In contrast to more strictly behavioral interventions, however, this approach does not adhere to a strict, pre-planned series of exposure activities. This is because the survivor's self capacities may be quite compromised, and his or her tolerance for exposure may vary considerably from session to session as a function of outside life stressors, level of support from friends, relatives, and others, and shifting transferential dynamics.
Exposure to abuse memories is complicated by the fact that there are probably at least two different memory systems to address: verbal and sensorimotor (8). The former is more narrative and autobiographical, whereas the latter involves the encoding and recovery of nonverbal experiences. Typically, material from both systems must be processed -- the first by repeatedly exploring the factual aspects of the event (e.g., who, what, where, and when), and the second by recollection of the images, sensations, and emotions associated with the abuse.
For abuse-focused therapy to work well, there should be as little avoidance as possible during the session. Specifically, the client should be encouraged to stay as "present" as he or she can during the detailed recall of abuse memories, so that exposure, per se, is maximized. In this regard, the very dissociated survivor may have little true exposure to abuse material during treatment -- despite what may be detailed verbal renditions of a given memory.
Effective therapy also capitalizes on the effects of therapeutic safety and emotional catharsis during the desensitization process. The positive feelings associated with emotional release (e.g., crying or raging), for example, may countercondition the distress initially associated with the trauma, just as traditional systematic desensitization pairs a formerly distressing stimulus to a relaxed (anxiety-incompatible)state.
At the same time that the client is encouraged to remember and to feel, he or she is also asked to think. For example, the client might explore the circumstances of the abuse, the basis for his or her reactions, and the dynamics operating in the abuser. This process is likely to alter the survivor's internal schema so that the abuse experience can be cognitively integrated (9). Abuse-related trauma work offers many opportunities arise for the reworking of harsh self-judgments (e.g., of having caused, encouraged, or deserved the abuse), as well as those broader self-esteem problems typically associated with child maltreatment. By exploring with the survivor the inadequate information and misinterpretations associated with such beliefs, the therapist can assist in the development of a more positive model of self.
Conclusion
Taken together, the approach outlined here allows the therapist to address the impaired self functioning, cognitive distortions, and posttraumatic stress found in some adults who were sexually abused as children. The serial desensitization of painful memories is likely to slowly reduce the survivor's overall level of posttraumatic stress -- a condition that eventually lessens the general level of dissociation required by the survivor for internal stability. This process also increases self resources -- as noted earlier, progressive exposure to non-overwhelming distress is likely to increase affect regulation skills and affect tolerance. As a result, successful ongoing treatment allows the survivor to confront and process increasingly more painful abuse-related material without exceeding the survivor's (now greater) self capacities. This process, under optimal conditions, may continue until substantial symptom resolution has occurred.
References
1. Berliner, L. & Elliott, D.M. (1996). Sexual abuse of children. In J. Briere, L. Berliner, J. Bulkey, C. Jenney, & T. Reid (Eds.), The APSAC handbook on child maltreatment. Newbury Park, CA: Sage.
2. Briere, J. (1995). Trauma Symptom Inventory. Odessa, FL Psychological Assessment Resources.
3. Briere, J. (in press). Psychological assessment of adult posttraumatic states. Washington DC: American Psychological Association.
4. Courtois, C. (1995). Some suggested guidelines of practice in therapy with adult clients possibly abused as children (those who initially report no memories of abuse or who do not disclose at the outset of therapy). Unpublished manuscript.
5. Briere, J. (1996). A self-trauma model for treating adult survivors of severe child abuse. In Briere, J., Berliner, L., Bulkley, J., Jenny, C, & Reid, T. (Eds.). The APSAC Handbook on Child Maltreatment. Newbury Park, CA: Sage Publications.
6. McCann, I.L., & Pearlman, L.A. (1990). Psychological trauma and the adult survivor: Theory, therapy, and transformation. New York: Brunner/Mazel.
7. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
8. van der Kolk, B., & Fisler, R. (1995). Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory study. Journal of Traumatic Stress, 8, 505-525.
9. Resick, P.A. & Schnicke, M.K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park: Sage.
John Briere, Ph.D., is Associate Professor of Psychiatry and Psychology at USC School of Medicine and an attending psychologist in the Division of Emergency Psychiatric Services of LAC-USC Medical Center. He is author of various articles, chapters, and psychological tests, primarily in the areas of child abuse, victimization, and psychological trauma. He has written or edited seven books, including Therapy for Adults Molested as Children: Beyond Survival (1st and 2nd editions), Child Abuse Trauma: Theory and Treatment of the Lasting Effects, and Psychological Assessment of Adult Posttraumatic States.
[footnote] Department of Psychiatry and the Behavioral Sciences University of Southern California School of Medicine[footnote] Address for Dr. Briere: USC Psychiatry, 1937 Hospital Place, Graduate Hall, Los Angeles, CA, 90033. Internet: jbriere@hsc.usc.edu.
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