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).