Written as MSW coursework for “Social Work with Victims of Violence Against Women,” at the Hunter College School of Social Work, this paper was honoured, in 1995, with (one of the five) Jacob Goldfein Awards for academic achievement.
Author: David Calhoun Mendelsohn
ABSTRACT: Recent studies have found that high percentages, (more than 50%), of psychiatric patients have histories of childhood abuse. How important issexual abuse trauma in the social workers’ client population? Dr. Judith Herman, author of Trauma and Recovery, (1992), and Dr. Bessel van der Kolk, of Harvard Medical School, cognizant of these high rates, have proposed a DSM diagnosis which focuses on “Complex” or “Extreme” stress disorders resulting from abuse, along with treatment specific to this major factor in the etiology of the pathology. This article reviews the mechanisms of “lost” and “recovered” memory in the context of trauma and recovery processes and proposes a diagnosis and treatment test of the Herman/van der Kolk theory.
The general theory which is the foundation of this paper’s proposal to create a new consciousness and practice throughout my agency, and a new unit within it, is that child, (physical and sexual), abuse has a far more profound effect upon our clients than is presently acknowledged, and that an orientation which focused on identifying it and working through its effects in treatment would result in more effective service to our clients.
I. THEORETICAL FRAMEWORK
From their work co-leading long-term psychoanalytically oriented group psychotherapy of persons with an early history of incest Gansarain and Buchele (1988) wrote in their book Fugitives of Incest, “The study of post-traumatic stress disorder (PTSD) in combat veterans provided a new understanding of symptoms that also affect victims of rape or incest. Incest meets the DSM-III diagnostic criteria for post-traumatic stress disorder, as it involves: (quoting from DSM-III, page 137)
(a) the existence of a recognizable stressorthat would cause distress in almost anyone; (b) the reexperiencing of the traumawith either intrusive recollections of the event, recurrent dreams about it, or sudden feelings and actions experienced as if the traumatic event were reoccurring (c) numbing of responsivenessto or reduced involvement with the external world, beginning after the trauma; (d) some of the following symptoms— hyper-alertness or exaggerated startle response, sleep disturbances, guilt about surviving, memory impairment or trouble concentrating, avoidance of activities that arouse recollection of the traumatic event, and intensification of symptoms by exposure to events that resemble the traumatic event.
Cole and Burney (1987) add a clinically critical descriptive element of the disorder when they point out indicative of the two basic presenting phrases:
As do victims of other traumas (earthquakes, torture, etc.), adult incest survivors frequently experience symptoms of post-traumatic stress. Their symptoms cluster into a stress response syndrome and cycle predictably in two major phases. An individual experiences phases of denial (over-controlling defences) which alternate with phases of an intrusive nature (under-controlling defences). Denial phase symptoms include amnesia (partial or full), forgetfulness, minimizing, dissociation, fatigue, headaches and selective inattention. Intrusive phase symptoms include hypervigilance, unbidden repetitive thoughts and imagery, hallucinations-like phenomena, confusion, waves of intense emotions, tremors, sweating, and nightmares.
As the data below will show, the linking of cases of child sexual abuse to those of disaster and war-related PTSD victims may well be far more important to our broadest etiological and therapeutic understanding of mental illness than we could have dreamed just twenty years ago. Following her familiarization with data cited by Dr. Judith Herman (1992), Dr. Mary Sykes Wylie, writing in The Family Therapy Networker(11-12/83) states that:
numerous well-documented studies done since 1987 indicate that 50-60% of psychiatric inpatients, 40-60% of outpatients and 70% of all psychiatric emergency room patients report childhood physical or sexual abuse, or both. To trauma researchers, this body of research suggests an intriguing new view of psychiatric etiology — that prolonged, severe childhood abuse may play a vastly underestimated role in the development of many serious pscyhopathologies now ascribed to biological factors, intrapsychic conflicts or standard family-of-origin issues.”
Herman (1992) adds that:
In the case of multiple personality disorder the etiological role of severe childhood trauma is at this point firmly established. In a study by the psychiatrist Frank Putnam of 100 patients with the disorder, 97 had histories of major childhood trauma, most commonly sexual abuse, physical abuse, or both…
In borderline personality disorder, my investigations have also documented histories of severe childhood trauma in the great majority (81%) of cases…
A recent study of women with somatization disorder found that 55% had been sexually molested in childhood, usually by relatives. This study, however, focused only on early sexual experiences; patients were not asked about physical abuse or a more general climate of violence in their families.
The implication here is that the link is probably stronger than the 55% cited.
Reviewing the above citations concerning the prevalence of sexual abuse victimization among mental health patients we are reminded of Freud’s (1896) early claim, based on his work with many patients, quoted from his The Aetiology of Hysteria, by Herman (1992):
I therefore put forward the thesis that at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience, occurrences which belong to the earliest years of childhood, but which can be reproduced through the work of psycho-analysis in spite of the intervening decades. I believe that this is an important finding, the discovery of a caput Nili(*source of the Nile) in neuropathology.
Just as in Freud’s time when he developed his theory based on listening to and believing his patients, (prior to his retreat from the “seduction theory”), some of the practitioners working closest to the patients of today have been grappling with the development of a new diagnosis for symptoms which had earlier been ascribed to different causes.
In the same Family Networkerarticle, Wylie lists symptoms which Dr. Bessel van der Kolk) of Harvard Medical School) and Herman cite as being consistent across the categories of PTSD, adult dissociation and childhood trauma:
inability to regulate emotions like rage and terror, along with intense suicidal feelings; somatic disorders (mysterious but debilitating physical complaints); extremely negative self-perception (shame, guilt, helplessness, self-blame, strangeness); poor relationships; chronic feelings of isolation, despair and hopelessness; and dissociation and amnesia. “They all go together,” says van der Kolk, “If you have one you have the others – it’s a package deal.”
Based on a five-year research project with 528 trauma patients, the most comprehensive ever done, a team of researchers led by Dr. van der Kolk, professor at Harvard Medical School and chief of the trauma unit of Massachusetts General Hospital, gathered what they considered sufficient data to justify the creation of a new diagnosis, “DESNOS,” or Disorders of Extreme Stress, Not Otherwise Specified, which includes the symptomatology listed above.
This proposed diagnostic definition parallels Herman’s proposed “Complex Post-Traumatic Stress Disorder” (1992). Both were considered for the forthcoming DSM-IV and both point to the link between severe psychiatric disorders and family violence. Based on what I am convinced is sufficient clinical experience and sound theory, their proposal: that various diverse disorders might better be understood and treated within this common diagnosis and guide the approach of clinicians, is warranted. It is that framework which is the central operating thesis of my proposal for the testing and development of a new project at my agency.
II. THE MECHANISMS AND MEANING OF MEMORY IN THE TREATMENT OF TRAUMA(S)
In his article in the Family Therapy Networker, David Calof (1993), writes:
During the past twenty years, I have worked as a therapist and consultant with more than 400 people who were cruelly and repeatedly beaten or sexually abused as children. While some came into therapy with memories of relatively minor abuse, very splitting, denial and projection, “each of these attempts to eliminate painful mental contents f rom the fields of awareness and memory.”
Below, I have excerpted pertinent descriptions of some of these ego defensers and their operation in relation to incest from Ganzarain and Buchele (1988):
Repression, a defense mechanism that operates unconsciously, denies unacceptable mental contents access to consciousness. These contents are representations, whether ideational, affective, or motor, of instinctual impulses.
Incest mobilizers all the motives that activate repression: guilt, anxiety, shame, and pain. Repression may then act as an anesthesia, providing either a “blackout of consciousness or a complete amnesia for the distressing facts…
Splitting is a schizoid mechanism described by Melanie Klein (1946) whereby the incipient ego mentally cuts off unacceptable aspects of the self or of its objects…
The splitting of objects leads to their being characterized as either “all bad” persecutors or “all good” idealized objects. By taking refuge in the relationship with the idealized object, the self is protected from the threatening persecutors…
Splitting of the self becomes pathogenic in victims of incest, contributing to the development of a false self, such syndromes as multiple personality, and also to disturbances of integration between the mental and bodily selves – sexual dysfunction, hypochondriasis, and anorexia.
Denial, a primitive defense mechanism that forms the core of manic reactions, defends against depressive anxieties experienced as guilt, sadness, and loss. Denial makes life look “rosy” by eliminating acknowledgement of such painful aspects of psychic reality as ambivalence toward lost objects and dependency on them…The presence of psychic pain is ignored and no efforts are made to relieve it.
Ganzarain and Buchele (1988) go on to say that these defences may operate in a combined operation rather than singly in more complex cases, but van der Kolk’s view, as outlined by Wylie (1993), goes even further in her view of the complexity of the human defense:
Traumatized people do not “repress their traumatic memories in the classic psychoanalytic sense, which refers to motivated “forgetting” of memories that evoke unpleasant internal conflicts. During trauma, the feelings and knowledge of what is successfully defended itself that it has constricted it’s domain to a small bemoated fortress, cut-off from the world and thus lacking in connection and feeling.
From this we can see that the key goal of “memory” is not the getting of the facts. As Breuer and Freud (1893-95) wrote, “recollection without affect almost invariably produces no result.” The key to the therapeutic effect is one of reintegration of the past with the present. As Herman (1992) put it:
The description of emotional states must be as painstakingly detailed as the description of facts. As the patient explores her feelings, she may become either agitated or withdrawn. She is not simply describing what she felt in the past but is reliving those feelings in the present. The therapist must help the patient move back and forth in time, from her protected anchorage in the present to immersion in the past, so that she can simultaneously reexperience the feelings in all their intensity while holding on to the sense of safe connection that was destroyed in the traumatic moment.
Or as David Calof (1993) wrote regarding his approach using hypnosis:
Hypnosis is not truth serum. The essence of its therapeutic value is that it can alter someone’s attitude toward his or her traumatic memories and blend past impressions with present day realities and beliefs. In this way, adult insights may be brought to bear on childhood perceptions…My practice is to wait for traumatic content to bubble up, rather than go looking aggressively for it. I believe that clients want to remember and tell their stories. If I provide a supportive, consistent, caring and empathic context, the client’s story will eventually come into the room.
And it is through the long process of the survivor repeatedly remembering and telling her story, thereby “working it through” that the reintegration is eventually accomplished and the split between the intrusive and constricted selves is healed. Through the “talking cure” the trauma victim is re-“membered”, slowly regaining her body and soul over time until one day, as Herman’s (1992) example shows:
the time comes when the trauma no longer commands the central place in her life. The rape survivor Sohaila Abdulali recalls a surprising moment in the midst of addressing a class on rape awareness: “Someone asked what’s the worst thing about being raped. Suddenly I looked at them all and said, the thing I hate the most about it is that it’s boring. And they all looked very shocked and I said, don’t get me wrong. It was a terrible thing, I’m not saying it was boring that it happened, it’s just that it’s been years and I’m not interested in it any more. It’s very interesting the first 50 times or the first 500 times when you have the same phobias and fears. Now I can’t get so worked up any more.”
III. THE COMPLEX POST-TRAUMATIC STRESS DISORDER SERVICES TEST
In light of the very large percentages of mental health clients who have histories of child (sexual and physical) abuse traumas, (cited above), a paradigm test of diagnosis and treatment is warranted.
The agency for which I am providing counselling services operates approximately thirty mental health, developmental rehabilitation, and employment units. These units employ the services of counsellors and therapists, including psychiatrists, psychologists, social workers, social work interns, nurses and employment counsellors. Each of these service providers currently work with psychosocial or psychiatric intake forms and most are already trying to identify possible problem areas for clients in order to assess the possible need for one kind of referral or another, or to make a psychiatric or developmental diagnosis. My proposal calls for these providers, who number in the hundreds, to be part of a two year test. One half of the number of each category of provider (psychiatrist, social worker, etc. will continue their work as before, while the other half will be sent to a fifty-four course which will familiarize them with Judith Herman’s and Bessel van der Kolk’s diagnostic schema(s), their theories and approaches to treatment.
New intake and evaluation forms would be introduced for use by this group that would follow the diagnostic criteria outlined by Herman/van der Kolk. So, rather than treating “borderlines,” “depressives,” “potential suicides,” “multiple personality” patients, etc. as such, they would be treated for “Complex Post-Traumatic Stress Disorder” both in individual therapy and concomitantly (through referral), when appropriate, to incest or abuse groups as well.
At intake and upon termination, both groups (including both patients/clients and therapists/counsellors would answer evaluation forms measuring progress, to assess the effect of the new paradigm shift in diagnosis and treatment.
Additionally, various methods would be tested, including EMDR, hypnosis, “flooding,” “testifying,” the use of psychoactive drugs, and individual and group therapy models.
IV. IMPEDIMENTS TO IMPLEMENTATION
POLITICAL: I would expect to meet overwhelming avowed and disavowed resistance to such a test, even with the funding in place. The taboo regarding sexual abuse should be expected to operate, and those who would insist that it is a far more prevalent social illness than currently acknowledged can expect to be treated to the kind of double-think that will paint the messengers with the “dirty” brush of their forbidden (taboo) message. Or as Herman (1992) puts it in her introduction to Trauma and Recovery, “The ordinary response to atrocities is to banish them from consciousness. Certain violations of the social compact are too terrible to utter aloud: this is the meaning of the word unspeakable.”
So, I would expect the board of my agency to come up with all kinds of excuses why their agency and their clients would be hurt by such a test program. If it was thought that the agency could still receive the funding, they might be willing to set up a separate corporate entity, and do the test on a far smaller scale.
LEGAL: Here I would foresee legitimate problems with my plan, that only a legal team could solve. Indeed, by anticipating a diagnosis not yet accepted, (and perhaps never to be accepted into the DSM), and then treating clients based on that diagnosis, FEGS might be open to lawsuits alleging they we were employing “unproven” methods.
This consideration causes me to suggest the possible necessity of all specifically emphasized memory retrieval work being done by referral to the unit itself andsuch referral, along with the specific method, being patient-chosen as much as possible.
PROFESSIONAL: Here I would expect many practitioners to have “professional” disagreements with the theory being “dictated” and the treatment methods being employed. The practice of any new ideas always involves change by the practitioner and change is always resisted to some extent. Again, with the target problem, sexual abuse, one should expect far more resistance than usual.
Here, a survey of practitioners, (designed as much as possible to avoid skewing the results of the test program itself), to identify those who would accept a change in their methods for a limited time and those who would not might could be utilized. From the results, most of those whose resistances is so great as to present reason for concern about their ability to provide adequate treatment would be eliminated in advance of the presentation of the plan. Then, a reasonable, and scientific presentation of the planned test might bring enough of those left with some reservations into sufficient compliance with the program.
CLIENTS: While it might “get around” that the agency is involved in a program that deals with child abuse, or sexual abuse, I’ve found clients to be less likely than professionals to deny the need to deal with problems that are known to exist but haven’t been faced. What the clients will want to see is effective work.
References
Breuer,J.,& Freud,S., (1893-95). Studies on Hysteria. In J.Strachey’s (Ed.), The Standard Edition, Vol.2. London: Hogarth Press.
Calof,D., (1993, September/October). Facing the truth about false memory. The Family Therapy Networker. pp. 38–45.
Cole,C.H.,& Barney,E.E., (1987, October). Safeguards and the therapeutic window: A group treatment strategy for adult incest survivors. American Journal of Orthopsychiatry, pp. 601–609.
Freud,S., (1896). The Aetiology of Hysteria. In J.Strachey’s (Ed.), The Standard Edition, Vol.3. London: Hogarth Press.
Gansarain,R.C.,& Buchele,B.B. (1988). Fugitives of Incest: A Perspective from Psychoanalysis and Groups. Madison,Ct.: International University Press.
Herman,J.L. (1992). Trauma and Recovery. New York: BasicBooks.
Wylie,M.S., (1993, September/October). The shadow of a doubt. The Family Therapy Networker, pp. 18-29, 70–73.
