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).