The National Council of Psychotherapists
PTSD in Victims of
By Jacquelyne Morison, BA, DACHp, MHS
This paper examines post-traumatic stress disorder (PTSD) as a condition exhibited by victims of sexual molestation. The first part provides a definition of PTSD, its symptoms and manifestations and emphasises those syndromes which are of importance to the practitioner who deals with cases of sexual molestation. The paper concludes by examining acknowledged treatment strategies, highlighting the values of each and comparing approaches.
What is PTSD?
The syndrome of PTSD results when a terrifying experience punctures an individual’s psychological existence and functioning so devastatingly that the aftermath leads to profound impairment of the ways in which he/she expresses personal emotions and deals with his/her normal environment – rendering recovery virtually impossible without therapeutic intervention.
PTSD was first recognised as shell shock or battle fatigue during the two World Wars but was not classified by the Diagnostic and Statistical Manual of Mental Disorders III (DSM-III) until 1980 after the Vietnam War when public awareness of numerous cases was significantly raised. DSM-IV-R (1994) defines PTSD as an anxiety disorder according to a collective five-axis diagnostic criteria succeeding traumatic exposure which results in persistent and pervasive symptoms of reliving the trauma, avoidant behaviour and autonomic hyperarousal. There is current debate, however, about whether PTSD should be more appropriately classified as a dissociative disorder in DSM-IV (Rothschild, 1998). Additionally, the International Statistical Classification of Diseases and Related Health Problems (1992) defines PTSD as a delayed or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature which is likely to cause pervasive distress and enduring personality change.
When Can PTSD Develop?
Post-trauma syndrome can develop when the individual experiences an overwhelming traumatic stressor, the most commonly cited of which are serious accident, man-made or natural disasters, sexual molestation, criminal assault, military combat, kidnap, imprisonment, violence, torture and witnessing or learning about highly traumatic incidents. Sexual assault (rape or attempted rape), childhood sexual abuse (incest, rape or sexual contact with an adult or much older child) and childhood physical abuse or severe neglect (beating, burning, restraint or starvation) are cited by Foa et al (1999) as constituting extreme stressors from which PTSD is likely to develop because personal human cruelty has far more devastating effects on the individual than, say, natural disaster or accident. Friedman (1997) specifically cites rape, torture, genocide and severe war-zone stress as being stressors which are likely to be subjectively registered as trauma by virtually everyone.
PTSD symptoms develop in the trauma-victim when the subjective perceptual impact of the stressor is exceptionally forceful because the traumatic event is outside the normal range of human experience and, therefore, engenders a powerful response of objective, realistically-founded anxiety which will debilitate his/her ability to cope with normal life. PTSD differs from commonplace stress in that while certain predisposing factors (such as a personality disorder and/or a previous history of neurotic illness) are capable of lowering the victim’s resilience-threshold or aggravating the condition via cognitive and emotional filtering, in the main, such factors are insufficient to justify the materialisation of symptoms. PTSD is, therefore, unique in that it is the only stress-inducing disorder which attributes the origin of a patient’s symptoms exclusively to the occurrence of a known, external etiological agent as opposed to emanating from within him/her because of, say, a personality defect, a biased subjective misattribution or a debased self-esteem. Moreover, even the most resilient individual will succumb to the effects of trauma in appropriate circumstances and symptoms will persist if untreated long after the originating stressor has been removed. Magnitude of exposure, previous experience of trauma and lack of social support are cited as the most significant predictors of PTSD development (Van der Kolk, 1994).
A rationale of the ways in which PTSD is viewed by various schools of thought is given below in Table 1 – Ratiocination of PTSD Symptomology.
Table 1 – Ratiocination of PTSD Symptomology
(Source: Amendolia, 1998; Foy, 1992; Hayes, 1998; Van der Kolk, 1994)
Maksakis (1996) postulates three levels of trauma victimisation with special reference to PTSD sufferers which cover
What are the Symptoms of PTSD?
The PTSD sufferer will experience symptoms which can cause significant distress and/or impairment in interpersonal, social and vocational functioning. Symptoms conform to a number of generally-agreed diagnostic criteria which collectively can secure a diagnosis of PTSD – covering patterns of physiological, affective, cognitive and behavioural functioning.
Exposure to Trauma
The PTSD sufferer will have personally experienced, have witnessed or have been confronted with a traumatic experience or catastrophic event which involved actual or threatened death, serious injury or threat to his/her physical integrity or to others. The adult sufferer’s response will have been one of intense fear, helplessness, horror, shock and confusion although children, whose comprehension of events will have been distorted, may display disorganised or agitated behaviour.
According to Harvey and Herman (1992), incest survivors and childhood sexual abuse victims suffer most noticeably from symptoms consistent with PTSD syndrome including nightmares, sleep disturbance, generalised anxiety, depression and dissociative disorders.
In a study of female psychotic patients, Beck and Van der Kolk (1987) and Craine et al. (1988) found that 66% of victims of childhood or adolescent sexual abuse met diagnostic criteria for PTSD. These patients suffered from intrusive, avoidant and hyperarousal symptoms and the study found distinguishing evidence of prominent sexual and abusive themes in their thoughts and behavioural patterns.
Foy (1992) claims that high exposure to trauma in the case of sexual assault victims and battered women doubles the risk for the victim of developing PTSD particularly in cases of completed as opposed to attempted rape. Baldwin (1997) also found that prolonged and repeated traumatic experiences in childhood increase the risk of the survivor’s developing PTSD.
Re-experiencing the Trauma
The adult PTSD sufferer will persistently re-experience or relive the original traumatic event with visual, auditory and somatic reality as if it were currently occurring. The manifestations of psychological reliving can be recognised when the sufferer:
In children with PTSD, the trauma may be re-experienced in terms of (a) repetitive play in which themes or aspects of the trauma are expressed, (b) frightening, content-free dreams and (c) trauma-specific re-enactment.
Distress and anxiety reminiscent of the original trauma may be triggered in the sexual molestation survivor, for example, by having sexual intercourse, by an unwarranted or unsolicited sexual approach or by sexual innuendo directed at the sufferer. Rape victims, in particular, have been known to react as if the approach of a stranger were precipitating a repeat attack (Van der Kolk, 1995). Matsakis (1996) emphasises that re-experiencing can also take a somatic form in the guise of physical pain or somatoform conditions such as genital pain, irritation, infection or sexual apparatus malfunction in survivors of sexual molestation.
Van der Kolk et al (1995) suggests that the element which distinguishes PTSD from other distress reactions is the fact that the patient becomes stuck in the intrusive reliving and re-enactment of thoughts and feelings. PTSD symptoms of this nature become a dominating psychological experience – epitomised by emotional flooding which can evoke panic, terror, grief and despair in the individual.
Laub and Auerhahn (1993) postulate a continuum of traumatic recollection and re-experiencing with reference to the time-distance from the traumatic experience, elements of which are not mutually exclusive, as set out below in Table 2 – Intrusive Re-experience Continuum.
Table 2 – Intrusive Re-experience Continuum
(Source: Laub & Auerhahn, 1994)
The PTSD sufferer will usually employ a number of unconsciously-motivated behavioural, cognitive and emotional strategies in an attempt to reduce exposure to trauma-mimetic stimuli and/or to minimise the intensity of his/her psychological response should such stimuli be unavoidable. The manifestations of avoidant behaviour can be recognised when the sufferer:
The victim of sexual molestation, for example, may wish to avoid sexual intimacy or contact, to escape from reports of sexual brutality or to sidestep a medical examination of an intimate nature.
Van der Kolk (1995) cited numbing of responsiveness as an instinctive baseline function in young children subjected to sexual abuse and claimed that learning difficulties in children are equal to overdependence in adults which can lead to aggression against the self. In a study of 87 psychiatric outpatients (Van der Kolk et al, 1991), found that self-mutilators invariably had histories of severe childhood abuse and/or neglect.
The PTSD sufferer will exhibit symptoms of increased autonomic arousal which were not present before the onset of the trauma. The manifestations of physiological hyperarousal can be recognised when the sufferer:
When threat or danger is perceived by the individual, this stimulates the limbic system in the brain (which regulates survival behaviour and emotional expression via hormonal activity directed towards the ANS) which can trigger the instinctive fight-flight-freeze response. When the organism is chronically aroused and continues to respond to such arousal, PTSD symptoms will appear as a result of the swamping effect on the amygdala (which stores and prioritises highly-charged emotional memories) and the hippocampus (which stores time-related and spatial memories according to the significance assigned to them by the amygdala) due to the fact that the emotional record of traumatic experiences cannot be properly processed and stored in the long-term memory. Such traumatic memories which are stored in associative networks in the brain, therefore, float in time and invade the sufferer’s present consciousness which, in turn, can exacerbate unhealthy physiological responses.
Bremner et al (1996) and Van der Kolk and Fisler (1994) report that studies have shown hippocampus degeneration in adult victims of childhood sexual molestation and that this may account for dissociative memory fragmentation.
Van der Kolk et at (1995) suggests that physiological hyperarousal is the central precondition for dissociative occurrence which, coupled with a lack of integration on a schematic level, causes the traumatic experience to be stored as affect states or as somatosensory elements which are ripe for reactivation because of the failure to integrate the experience into autobiographical memory. Such symptoms can often lead to comorbid diagnoses such as anxiety attacks, social phobias, depression, obsessive-compulsive disorders, suicidal ideation, self-mutilation, substance abuse, drug dependence, manic activity bouts, chronic fatigue syndrome and personality disorders.
PTSD Syndromes and Manifestations
PTSD symptoms are classified by DSM-IV-R in terms of their duration and onset as being (a) acute when symptom-duration is between 1–3 months, (b) chronic when symptom duration persists in excess of 3 months and (c) delayed onset when symptom onset manifests in excess of 6 months after the occurrence of the traumatic incident. Other researchers have, however, identified varying permutations of the original DSM diagnostic criteria which have produced subcategories of relevance to the clinician.
Delayed Onset PTSD
With delayed-onset PTSD – which is particularly prevalent in cases of sexual molestation – a latency period prior to the gestation of the condition may range from a few months (as with adult sexual assault victims) to several decades (as with adult survivors of childhood sexual abuse). Delayed-onset PTSD symptoms will often engender chronic distress with minimal provocation and may result in the development of a conditioned emotional response in the victim due to continual exposure to dormant or unresolved traumatic experiences.
Delayed-onset PTSD may be triggered in the survivor of childhood sexual abuse by events such as sexual assault in adulthood, pregnancy or childbirth, his/her own child reaching the same age as he/she was when victimised, entering adolescence or experiencing a mid-life crisis, meeting or confronting his/her abuser, the death of his/her abuser and overcoming an addiction (Fredrickson, 1992).
A recent traumatic experience can lead to reactivated PTSD when the recollection of an earlier trauma, from which a patient has ostensibly recovered, can, subsequently, evoke accumulated or secondary PTSD symptoms. Secondary traumatisation can, of course, occur if the victim experiences additional trauma, is unsympathetically treated, is unfairly blamed or stigmatised, is subjected to enforced disclosure and/or submits to brutal or overly inquisitive questioning.
According to Hiley-Young (1992) and Solomon et al (1987), reactivated PTSD may be classified as either uncomplicated reactivation or complicated reactivation. Uncomplicated PTSD reactivation occurs when (a) the client’s current trauma is reminiscent of his/her previous trauma-experience, (b) his/her previous symptoms are reactivated after a symptom-free period and (c) he/she is characterologically intact but is unable either to assimilate or to tolerate any feelings associated with trauma. Complicated PTSD reactivation occurs when (a) the client’s residual PTSD symptoms are exacerbated, (b) he/she experiences increased sensitivity and vulnerability to stressors and traumatic stimuli unrelated to the original trauma experience and (c) he/she has severe characterological disturbance which manifests as identity disturbance, feelings of alienation, mistrust and extreme interpersonal difficulties.
Complex PTSD Syndromes
Herman (1997) and Coffey (1998) both take the view that the official diagnosis of PTSD is inadequate to account for the symptoms experienced by victims of sexual molestation and have called for new diagnostic labelling to describe the after-effects of sexual traumatisation – postulating Complex PTSD, Victimisation Sequelae Disorder and Disorders of Extreme Stress Not Otherwise Specified (DESNOS) as being more comprehensive titles in such cases.
Herman (1997) explains that a three-level trauma response can consist of an early crisis-level response which precedes the manifestation of PTSD symptoms followed by the development of comorbid symptoms which can coexist with PTSD disorders if the condition remains untreated. Furthermore, Maksakis (1994) specifically cites survivor guilt, self-blame, secondary wounding, low self-esteem and victim thinking as being problems typically exhibited by PTSD sufferers which have not been identified within the DSM-IV diagnosis.
Herman (1997) proposes that victims of childhood sexual abuse suffer from a Complex PTSD syndrome – akin to Post-Traumatic Personality Disorder – which is said to result when the client has been exposed to prolonged traumatic experience in childhood with particular reference to sexual abuse. She found that 81% of borderline personality patients had a history of childhood abuse trauma. Complex PTSD syndrome comprises (a) behavioural difficulties (such as impulsivity, aggression, sexual acting out, sexual expression abnormalities, eating disorders, substance abuse, compulsive gambling and self-destructive actions), (b) emotional difficulties (such as affect lability and regulation, rage, depression and panic), (c) cognitive problems (such as fragmented thoughts, dissociative symptoms and amnesia) and (d) somatic symptoms characteristically associated with the original traumatic incident.
Herman (1997) also alludes to a syndrome of chronic trauma – an insidious and progressive form of PTSD which can develop in survivors of sexual molestation who have been subjected to forms of repeated abuse (such as on-going incest or multiple rape) whereby the victim loses his/her sense of self and feels as if his/her personality has irrevocably eroded because of a pervasive dread that the horror will recur.
Rape-trauma syndrome (RTS) was first identified by Burgess and Holmstrom (1974) who outlined a two-stage reactionary process to the incidence of rape. The initial acute disorganisation phase is characterised either by expressive reactions such as fear, anger, anxiety, sobbing and tenseness or by controlled reactions whereby the victim displays a calm exterior. The secondary reorganisation phase is depicted by lifestyle rebuilding and readjustment when the victim undertakes action to ensure his/her safety (e.g. moving house, rearranging furniture, changing telephone numbers, reading about the syndrome and joining self-help groups).
RTS goes hand in hand with PTSD in that as many as 95% of victims exhibit PTSD symptoms within two weeks of the rape incident (Rothbaum et al, 1992), the most prominent manifestations of which are reliving the trauma, sleep disturbance, exaggerated startle response, sexual activity avoidance and nightmares – particularly in the case of "blitz rape" (when the victim is awakened suddenly by the perpetrator).
Braswell (1992) speaks specifically of rape-related post-traumatic stress disorder (RR-PTSD) which encompasses four major symptoms of (a) reliving and experiencing trauma whereby the victim is plagued by intrusive thoughts, nightmares and flashbacks, (b) social withdrawal whereby he/she experiences psychic numbing, denial, emotional deadening and lack of interest, (c) avoidance behaviours whereby he/she avoids potential triggers and (d) increased hyperarousal whereby he/she exhibits hyperalertness, hypervigilance and sleep disorders. Braswell also highlights the fact that permanent physiological changes may lead the victim to perceive all events as crises and that, in consequence, alcohol and drug consumption may become a coping strategy.
A survey of female rape victims indicated that 31% of all victims develop rape-related PTSD at some point in their lives and that the consequences of this are an increased tendency towards alcohol and substance abuse (Harvey & Herman, 1992). Furthermore, rape victims remain fearful of the stigma, the blame and public disclosure for years after the assault which renders them liable to major depression (National Victims Center, 1992). Sexual assault perpetrated by persons known or closely associated with the victim result in more devastating consequences because of the betrayal factor and have a more lasting impact with both rape victims (Koss et al, 1987; Roth et al, 1990; Russell, 1984; Wyatt 1985) and adult survivors of incest (Herman et al, 1986).
It has been noted that rape victims and adult survivors of childhood sexual abuse have fairly good psychosocial adjustment but react to pressure and normal stress as if it were trauma (Van der Kolk, 1994). Moreover, sexual victimisation in childhood has proved a reliable predictor of a heightened risk of vulnerability to rape in adulthood (Koss & Harvey, 1991; Russell, 1986).
Recovery from rape attacks has been reported in 75% of cases four to six years after the incident although very distressed or numbed victims and those who have suffered excessive or life-threatening violence have had a poor recovery outcome and 16% of these casualties were still suffering from PTSD symptoms 17 years after the event (Rosenhan & Seligman, 1995).
The therapist who treats PTSD sufferers can personally suffer from a form of reflective, secondary traumatic reaction known as compassion fatigue or vicarious victimisation (Herman, 1997).
The symptoms associated with this syndrome are intrusive cognitions, nightmares and survivor guilt complexes which can interfere with therapeutic neutrality and client-therapist boundaries due to a combination of inexperience with trauma victims and counter-transference. Such reactions may also evoke avoidant coping strategies in the therapist such as doubting, denial, disavowal, isolation, minimisation, dissociation, intellectualisation and constricted affect which can seriously impair the client’s progress in therapy as well as vitiate the therapist’s vocation (Friedman, 1998). Friedman advocates self-care activities for the therapist who regularly works with trauma survivors in the form of in-depth personal therapy, regular supervision, case load monitoring, appropriate boundary establishment and support network maintenance.
PTSD Treatment Strategies
PTSD treatment strategies have been summarised as consisting principally of exposure therapy, meaning alteration, coping skills training and social support methodology (Hyer, McCranie & Peralme, 1993). A distinction can be made between those therapists who advocate a learning framework which emphasises anxiety reduction, affect modulation and behaviour extinction (e.g. exposure therapy or systematic desensitisation) and those who favour a cognitive perspective in which material is reorganised and integrated (e.g. cognitive restructuring). A combination of both of these approaches has been validated in clinical trials involving psychoeducation, exposure therapy and cognitive reattribution with victims of sexual trauma (Resick & Schnicke, 1992).
Van der Kolk (1994) proposes PTSD treatment methodology based on three principle components of (a) processing and coming to terms with the horrors of the overwhelming experience, (b) controlling and mastering physiological and biological stress-reactions and (c) re-establishing secure social connections and interpersonal efficacy. The aim of such an approach would be to enable the trauma survivor to cease to be hauntingly dominated by the seeding event(s) and to become fully capable of current-day responding, the key elements being cited as (a) the integration of the alien, unacceptable, terrifying and incomprehensible elements of the adverse experience, (b) the stabilisation and deconditioning of anxiety and (c) the restructuring of the pervasive effects which the trauma has had on the victim’s self-appraisal and outlook.
Friedman (1998) also advocates that therapeutic intervention should conform to a pattern of
Similarly, Herman (1997) postulates a therapeutic approach with particular reference to victims of sexual molestation which provides a safe environment for the client, allows for remembrance and mourning followed by reconnection and reintegration in order to address the client’s issues of betrayal and powerlessness impregnated with terror.
Hypnosis is generally regarded as an ideal treatment-medium for PTSD clients because the dissociative elements of the condition render the subject susceptible to hypnotic intervention and open to beneficial therapeutic suggestion. Herman (1997) points out that victims of sexual molestation often develop trance capabilities in order to dissociate from the experience of repeated traumatic incidents but that these altered states of consciousness engender a multiplicity of symptoms.
According to The International Society for Traumatic Stress Studies (in press) hypnotic techniques can stabilise the patient by inducing calmness, strengthening the ego, providing a degree of safety and reassurance, resolving and integrating traumatic memories, modulating emotional responses, recontextualising the event(s), providing adaptive coping strategies, heightening self-esteem and strengthening self-image. Hypnotherapy used with PTSD patients can, essentially, propitiate confrontation with traumatic material, facilitate conscious experience of dissociative elements, initiate confession and consolidation, provide an environment for sympathetic understanding, allow for condensement of aspects of the original trauma and enhance concentration, mental control and adaptive congruence.
A study by Brom et al (1989) using suggestive methodology revealed a significant decrease in intrusion and avoidance symptoms. This study achieved phased stabilisation using techniques for (a) relaxation, ego-strengthening and memory containment, (b) memory resolution, modulation of emotional and cognitive responses and (c) experience integration and adaptive response acquisition.
The medium of hypnosis can also synergistically integrate with both psychodynamic and cognitive-behavioural approaches. Combined behavioural and psychodynamic techniques are advocated by Davies and Frawley (1994) but they warn that hypnosis can resemble invasive control and domination and that its memory enhancement capabilities may bring about pseudo-memories if it is inexpertly employed.
Amendolia (1998) gives an Ericksonian perspective on the treatment of PTSD by pointing out that the individual is usually attempting to undertake problem solving, even in a dissociative state, when trauma strikes and is calling for help, for example, when experiencing an intrusive recollection or when having a recurring dream.
The goal in Ericksonian hypnosis, therefore, would be not only to encourage structured dissociation in the entranced client in order to facilitate cognitive flexibility by broadening beliefs and choices but also to recontextualise his/her traumatic memories which can evoke fearful emotions and physiological hyperarousal. The outcome of this approach would be to empower the client with self-mastery, competence and confidence by creating a feedback loop whereby traumatic memories are linked to healthy neural pathways which can be consciously accessed at will rather than uncontrollably and intrusively experienced – thus making such memories acceptable to the patient.
Critical Incident Stress Debriefing
Critical incident stress debriefing (CISD) has been established as the obvious group treatment choice for on-the-scene crisis intervention because it can aid survivors in making sense of their symptoms and can help to avert the development of PTSD.
CISD is a structured crisis-management process which helps the trauma survivor to understand and to manage intense emotions, to identify personal coping strategies and to receive peer support with the emphasis on education, self-regulation and rebuilding. It provides a narrative understanding of crisis experiences by dealing with the immediate impact and initial effects of the trauma, assists re-adjustment and life reconstruction but is not regarded as a substitute for longer-term psychotherapy or counselling (Parkinson, 1997). CISD, therefore, may form part of an overall critical incident stress management (CISM) programme in which psychotherapeutic and counselling techniques are additionally employed.
The CISD procedure adheres to an initial debriefing protocol (IDP) which enables the survivor to cathartically verbalise and to reflect on his/her experiences and a follow-up debriefing protocol (FDP) which enables him/her to fully incorporate a coherent understanding of his/her experiences. Debriefing protocols usually consist of eight overlapping and/or repeatable phases as set out below in Table 3 – Critical Incident Stress Debriefing.
McFarlane (1994) has established that psychological debriefing equips survivors with a better chance of recovery from trauma compared with a lack of therapeutic intervention following a traumatic event. The success or otherwise of debriefing has been found to hinge on the timing relative to the critical incident, whether one-to-one or group sessions are suitable for the survivor, the number and duration of sessions, the quality of the education provided and the alliance forged between the debriefer and the participants (Young et al, 1998).
In a survey of medical and clinical practitioners (Foa et al, 1999), psychoeducation about expected trauma effects and recovery prognoses as a preventive agent against the development of PTSD was favoured by 59% of respondents as a treatment strategy during the first month after the trauma had occurred and by 53% of respondents in cases of acute PTSD in order to avert the development of chronic symptoms.
General group techniques which include CISD elements have been effectively employed both with adult survivors of childhood sexual abuse (Herman & Shatzow, 1987; Ganzarian & Buchele, 1987; Schacht et al, 1990) and with rape-victims (Yassen & Glass, 1984).
Table 3 –Critical Incident Stress Debriefing
Source: Young et al, 1998; Parkinson, 1997)
Post-disaster cognitive-behavioural therapy (CBT) aims to correct behaviour-patterns and faulty cognition associated with painful and intrusive thoughts by means of relaxation training, thought challenging, sensory exposure, defusion and integration and is founded on the premise of strategic, sequential phasing of crisis management and psychosocial stabilisation of the individual.
CBT usually consists of phased interventions as set out below in Table 4 – Cognitive-Behavioural Therapy.
Table 4 – Cognitive-Behavioural Therapy
Source: Young et al, 1998
The strengths of the CBT protocol in treating PTSD survivors reside chiefly in self-understanding and cathartic release of traumatic material. In principle, the therapist’s role would be to help the client to understand that his/her responses of hypervigilance, dissociation and/or avoidance are activated by a natural, self-protective mechanism and to appreciate that any reliving of the trauma during the direct therapeutic exposure (DTE) phase is a route towards emotional release, resolution of psychic turmoil, self-efficacy and increased optimism for the future.
The two major therapeutic goals advocated by Foy (1992) for treating cases of sexual molestation are anxiety reduction related to conditioned stimuli in the form of stress inoculation training (SIT) and perception alteration in terms of physiological, affective and cognitive responses although he concedes that exposure therapy has a most lasting efficacy.
Chu (1998) emphasises that purely abreactive work which has its origins in combat-related PTSD is insufficient in cases of severe childhood sexual abuse and could, indeed, lead to secondary traumatisation if such therapy is not handled expertly and supportively by the therapist because of the complex and confusing nature of the characteristic dissociative symptoms.
Eye Movement Desensitisation and Reprocessing
Eye movement desensitisation and reprocessing (EMDR) is a controversial, yet clinically well-supported, treatment based on the premise that trauma causes psychological dissociation of hemispheric processing and implicit memory impairment which leads to the development of erroneous self-beliefs. With EMDR therapy, the patient is instructed to recall a painful traumatic episode when focusing on a means of mapping rapid saccadic movement which mimics REM while, simultaneously, replacing a self-referent negative cognition associated with the traumatic memory with a positive one – thus combining direct exposure techniques with cognitive elements.
Shapiro (1989) deems that such saccadic movement can reprogram brain functioning by transferring traumatic data from the cortical right-brain hemisphere to the left-brain hemisphere in order to allow memories to be properly processed, stored and reintegrated. Sensory inputs can be analysed and integrated with left-hemisphere cognitive functions during the desensitisation part of the process so that trauma events can be recontextualised and affective arousal can be neutralised or modulated during the reprocessing phase. This technique utilises a heighten state of awareness akin to hypnosis brought about by collaborative, structured dissociation in order to facilitate the orientation of the client’s traumatised conscious mind towards revisiting traumatic memories and, simultaneously, to instigate the organisation of a self-narrative reconstruction which juxtaposes his/her hyperarousal states with his/her personal perception of events.
Purnell (1999) believes that the clinician will be challenged when dealing with victims of childhood sexual abuse because of the fragmented and/or repressed nature of memory in such cases in that the client may have a vague or non-existent recollection of the trauma. Purnell suggests a phased EMDR programme for sexual abuse victims which focuses on issues of restoring a feeling of safety and control, apportioning blame, securing appropriate boundaries, improving dysfunctional relationships, restoring body-image, renewing self-awareness, reclaiming sexuality, rebuilding self-esteem and neutralising negative emotions of fear, anger, shame and grief.
A summary of EMDR therapy is outlined in Table 5 – Eye-movement Desensitisation and Reprocessing.
The controversy over the way in which EMDR therapy functions waivers between whether its purpose is to link the client’s logical functioning to his/her emotional, sensual and physical memory (Call, 1995) or, alternatively, to enable him/her to face the trauma and to seek a positive outcome (Maksakis, 1996). The main pockets of research have come from Shapiro (1989) and Wilson et al (1995) who claim proven efficacy using EMDR with PTSD sufferers including known victims of childhood abuse.
Table 5 – Eye-movement Desensitisation and Reprocessing
Source: Purnell, 1999
McNally (1999) judges that 3 out of 5 reported studies have indicated the superiority of EMDR over contrasting treatments for PTSD. EMDR has been found to be significantly superior to relaxation training (Carlson et al, 1998) in treating PTSD although exposure therapy combined with skills training showed some superiority over EMDR (Devilly & Spence, 2000).
Rothbaum (1997) found that 90% of rape-victims noted a decrease in PTSD symptoms after only 3 sessions of EMDR. Datta and Wallace (1996) tested a number of adolescent victims who had themselves become abusive perpetrators and proved superiority for EMDR over other methods of treatment.
Foa et al (1995) and Pitman et al (1993) argue that EMDR is really exposure therapy in disguise and that eye movement may be superfluous to the process. The EMDR controversy has also fuelled the debate about false memory syndrome in which proponents vehemently dispute the fact that patients are capable of retrieving repressed traumatic memories – particularly from childhood – which, subsequently, cannot be authenticated and which can lead disastrously to false allegations.
Psychodynamic methodology examines the client’s personal values and the ways in which experiences have affected him/her by helping him/her to develop effective approaches to resolving and managing unconscious emotions and beliefs which stem collectively from formative relationships and from current trauma.
Psychodynamic persuasions embrace stages as set out below in Table 6 – Psychodynamic Therapy.
Table 6 – Psychodynamic Therapy
Source: Young et al, 1998
Psychic conflicts often centre on issues of betrayal, abandonment, rejection, coercion, entrapment, intimidation, humiliation and the withholding of affection involving both intraphysic and interpersonal dilemmas as well as issues of guilt, shame and despair – all factors of which are of particular relevance to the sexual molestation survivor. Psychodynamic techniques are also directed towards the unearthing of suppressed or repressed fearful traumatic memories using free association methodology.
Davies and Frawley (1994) suggest that psychodynamic methods for cases of childhood sexual abuse should conform to an integrative approach which considers factors relating to the symbolic encoding of traumatic memories, dissociative systems, object representations, spontaneous regression, disorganisation, hyperactivity and trauma response to arbitrary stimuli. They postulate a treatment model based on containing the impact of the trauma, facilitating the disclosure of memories and fantasised elaborations, accelerating recovery, exploring eidetic symbolisation, investigating the encoding of memories and experiences, integrating disparate parts of the self, peeling away defences and resolving dysfunctional object-representations and relationships.
Interpersonal therapy (IPT) focuses on a here-and-now framework in order to bring about improvements in the patient’s personal relationships. IPT specifically concentrates on issues of psychosocial relational impairment, severance and/or dysfunction brought about by emotional numbing, detachment, loss of interest, loneliness, irritability, frustration, mistrust and hypervigilance which impose strain on communicative interaction. This approach helps the client to overcome avoidance of and limitations to interpersonal communication in times of conflict, to rectify over-involvement in significant relationships and to address depressive symptoms which may be linked to issues of bereavement, role conflict, relational responsibilities and transitions.
The sequential phases of IPT are set out in Table 7 – Interpersonal Therapy.
Table 7 – Interpersonal Therapy
Source: Young et al, 1998
Emotion-focused therapy (EFT) concentrates exclusively on appraising and utilising the client’s unexpressed or unrecognised emotions which can lead to impaired coping abilities and personal problems in order to overcome traumatic fears, improve key relationships and resolve inner conflict.
Emotional change in EFT practice involves (a) unearthing the client’s awareness of subtle or dismissed emotions (such as guilt and fear), (b) intentionally evoking emotions in order to harness motivational potential, (c) restructuring emotions by focusing on personal and interpersonal dilemmas via role-play or imaginative re-enactment, (d) identifying and altering destructive thoughts or beliefs (known as "hot cognitions") which can trigger or sustain intense emotions and subsequent behaviour, (e) planning therapeutic exposure to emotion-evoking scenarios and (f) reworking relational involvement.
Within Neuro-Linguistic Programming (NLP), the visual-kinaesthetic dissociation (V-KD) technique can be used to encourage the client to review a traumatic incident in a dissociated manner in order to divorce his/her feelings from the visual memory of the event. V-KD has been cited in research as showing a positive reduction in anxiety in teenage rape victims (Koziey & McLeod, 1997).
Traumatic Incident Reduction Therapy
Traumatic incident reduction (TIR) therapy is a method of reducing or eliminating the effects of trauma, related negative emotions and dysfunctional cognitions. The facilitator asks the client to repeatedly review a traumatic incident – and any previous incidents related to it – both verbally and silently until an end-point resolution is achieved whereby he/she can acknowledge the personal significance of his/her recollections in order to consciously consign such material to insignificance. TIR claims theoretical and empirical evidence to support the fact that its strengths reside in repetitive imaginal exposure as the only effective ingredient in treating PTSD (Moore, 2000).
Thought-field therapy (TFT) utilises the energy meridians of the body to order to relieve traumatic memories. The therapist asks the client to physically tap repeatedly in a precise sequence on specific acupuncture points while focusing on traumatic recollections and reciting positive affirmations.
Tapas Acupressure Technique
Tapas acupressure technique (TAT) is used to relieve traumatic distress and allergic reactions by combining acupressure techniques with memory recall and positive affirmations.
Time-limited Trauma Therapy
Time-limited trauma therapy (T-LTT) is a video-assisted exposure therapy in which the client engages in a non-abreactive memory process and then reviews recursive videotape recordings of his/her reactions in order to defuse his/her traumatic responses.
It seems clear from significant research in this field that most victims of sexual molestation, abuse, violation or defilement will suffer from symptoms of PTSD in one form or another. Most of the research undertaken has focused on rape victims who have displayed symptoms unique to their distress which falls short of the DSM diagnostic criteria and, therefore, has lead to the formulation of certain rape-specific syndromes based on PTSD. Additionally, research has established the fact that rape victims who were victims of sexual abuse in childhood will have an even greater risk of developing chronic or complex forms of PTSD.
Therapeutic intervention for PTSD is extraordinarily complex in that, on the one hand, the patient will be dealing with devastating emotional experiences which will require him/her to plummet the depths of unconscious probing and to dredge up the most heartrending of abreactive expression while, simultaneously, he/she will be required to reshape cognition, outlook, self-image and social interaction.
Because of its complexity, therefore, the emphasis in PTSD therapy should, in general, be on global treatment regimes rather than on merely focusing on one specific cluster of symptoms using a single methodology. This particularly holds true when treating victims of sexual molestation who may suffer from a range of PTSD symptomology together with comorbid disorders.
While group methods of crisis intervention, such as CISD, can avert the establishment of PTSD, it is generally considered that psychological debriefing alone is not a comprehensive solution for long-term recovery. Some supplementary form of ongoing individual therapy will usually be required which has the advantage of providing personalised, tailor-made treatment for the trauma victim who may not wish to freely air his/her thoughts and feelings in the group setting.
Uncomplicated PTSD often responds well to short-term methodology, such as CBT, hypnosis and DTE processes, in cases where single trauma incidents have occurred and no comorbid symptoms coexist. It is, however, important to understand that when dealing with victims of sexual molestation using rapid treatments such as EMDR, TIR, T-LTT and V/KD, the practitioner should not only be highly trained in these approaches but also well versed in the treatment of PTSD, comorbid disorders and in handling dissociation, regression and abreaction.
Longer-term psychodynamic techniques, alternatively, have the benefit of both expressive and supportive elements for the client but require that he/she have determination, strong-mindedness and a capacity for insight – attributes not always readily available in victims of sexual violation. However, often such in-depth treatment may be the only viable solution for cases of severe, repeated or multiple traumatisation because it takes an all-embracing approach to the client’s recovery.
Foa et al. (1999) found, in research, that clinicians highly rated (a) anxiety management (relaxation training, breathing retraining, positive thinking, positive self-talk, assertiveness training and thought stopping), (b) cognitive therapy which can modify unrealistic assumptions, beliefs and automatic thoughts and (c) direct therapeutic exposure both imaginal and in vivo as an initial treatment-regime for PTSD. Research participants, however, were less enthusiastic about EMDR, classic hypnotherapy and psychodynamic processes as a first-line treatment strategy. Cognitive therapy was favoured by 65% of clinicians as a first choice of treatment for issues of guilt and shame while exposure therapy was preferred for trauma-related fears, panic and avoidance (57%), flashbacks (53%) and intrusive thoughts (53%).
Sensory flooding or exposure, particularly combined with hypnosis, which may temporarily exacerbate the client’s symptoms prior to recovery should, however, be used judiciously in order to avoid retraumatisation and the therapist needs to provide reassurance and be trusted implicitly by the client for this to be achieved successfully (Davies and Frawley, 1994). An unsympathetic or unskilled therapist can inadvertently re-activate trauma – a situation which must be avoided at all costs. For victims of sexual molestation, the most important therapeutic components will be those of establishing trust, of ensuring a safe environment for disclosure and of providing psychoeducation. The clinician should pursue a regime which encompasses these elements while, simultaneously, addressing the range of issues likely to be exhibited by victims of sexual traumatisation within an integrative framework. A combination of the following two approaches may achieve this aim and provide a structure on which the clinician in his/her chosen discipline can build when dealing with victims of sexual molestation because the first outlines a general approach to the treatment of PTSD while the latter concentrates specifically on victims of sexual molestation.
Ochberg (1993) suggests that PTSD therapy, in keeping with the principles of hypnosis, should adhere to a process of (a) normalisation in which a general pattern of adjustment is pursued by dealing with issues of re-experiencing, avoidance, sensitivity, self-blame and survivor guilt, (b) collaboration and empowerment in which issues of powerlessness and dehumanisation are addressed and (c) individuality in which the patient’s personal pathway to recovery is identified and exploited. Maksakis (1996) regards effective treatment for sexual molestation victims as a process of remembering the trauma, expelling feelings of fear, rage, guilt, grief and powerlessness and attaining self-empowerment which may have produced impaired sexual performance, sexual identity confusion, misattribution of blame and feelings of betrayal and physical impingement.
Sources of Reference
Jacquelyne Morison is a highly experienced practitioner in the field of post-traumatic stress disorder who has a private practice both in London and in Kent. She also runs courses for therapists who wish to qualify in Post-traumatic Stress Disorder Therapy and Victims of Childhood Abuse Therapy in the UK and abroad. For details of these course, please contact The International College of Ecectic Therapies on Tel ++ 44 (0) 20 8446 2210, Fax ++ 44 (0) 20 8343 9474, Email email@example.com or Web site www.icet.net.
Web site - www.btinternet.com/~jacquelyne.morison
And E-mail - firstname.lastname@example.org
(This article was first published in Empathy - Summer 2000, Vol. 2, issue 2, pp.7-20. We are grateful to the Hypnotherapy Society & the author for permission to reproduce this article…)