Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life

352 Pages·2006·1.7 MB·English

by  Marylene Cloitre Phd

Treating Survivors of Childhood Abuse

Treating Survivors
of Childhood Abuse
(cid:1)
Psychotherapy for
the Interrupted Life
MARYLENE CLOITRE
LISA R. COHEN
KARESTAN C. KOENEN
THE GUILFORD PRESS
New York London
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LibraryofCongressCataloging-in-PublicationData
Cloitre,Marylene.
Treatingsurvivorsofchildhoodabuse:psychotherapyfortheinterruptedlife/Marylene
Cloitre,LisaR.Cohen,KarestanC.Koenen.
p.cm.
Includesbibliographicalreferencesandindex.
ISBN-10:1-59385-312-2 ISBN-13:978-1-59385-312-9(pbk.)
1. Adultchildsexualabusevictims—Treatment. 2. Psychotherapy. I. Cohen,LisaR.
II. Koenen,KarestanC. III. Title.
[DNLM: 1. StressDisorders,Post-Traumatic—therapy. 2. ChildAbuse—
therapy. 3. Survivors—psychology. 4. Adult—psychology. 5. Psychotherapy—
methods. WM170C643t2006]
RC569.5.A28C482006
616.85′83690651—dc22
2006007900
This book is dedicated to
Caleb
for his inspiring optimism and capacity for love
and to all other children for whom we hold
the enduring wish that they grow up to be
their best possible selves
A survivor ultimately has two psychological possibilities: to shut down or
to open up. Usually the survivor does both. . . . The protean self opts for
opening out. . . . This includes the basic satisfaction, even joy, in being
alive, in not having died, along with the sense of having undergone an
experience that is illuminating in its pain. Survival also implies
persevering, holding on, maintaining one’s existence . . . a physical and
mental strength. That sense of victory over destruction is evident in
gatherings of survivors . . . where one hears clearly the words, even if
actually unspoken: “We are here! We’re alive! We have won!”
—ROBERT JAY LIFTON (1993, pp. 81, 82)
About the Authors
MaryleneCloitre,PhD,isthefoundingdirectoroftheInstituteforTraumaandStressattheNew
YorkUniversityChildStudyCenterandisalsoNYU’sfirstCathyandStephenGrahamProfessorof
ChildandAdolescentPsychiatry.Dr.Cloitre’sprimaryclinicalandresearchinterestsfocusonthe
developmentalconsequencesandtreatmentofchildhoodabuseinadultsandadolescents.Shehas
published widely on this topic and has received several grants from the National Institutes of
Healthandotheragenciesforevidence-basedinterventionandpreventionprogramsaddressingthe
psychologicalandsocialeffectsoftraumainadultsandchildren.Dr.Cloitreiscurrentlyamember
oftheBoardofDirectorsfortheInternationalSocietyforTraumaticStressStudiesandwasamem-
beroftheAmericanNationalCommitteetoDevelopTreatmentGuidelinesforPTSD.Shereceived
her BA in philosophy from McGill University and her PhD from Columbia University.
Lisa R. Cohen, PhD, is a Research Scientist with the Social Intervention Group at the Columbia
UniversitySchoolofSocialWork,whereherworkfocusesondevelopingandtestingtreatmentsfor
womenwithPTSDandsubstanceusedisordersthroughgrantsfundedbytheNationalInstituteon
DrugAbuse.Shealsoconductsresearchontheimpactoftraumaonparentinganditsintergenera-
tional implications. Dr. Cohen maintains a private psychotherapy practice in New York City spe-
cializinginthetreatmentofcomplextraumadisorders.ShereceivedherBAfromtheUniversityof
PennsylvaniaandherPhDinclinicalpsychologyfromYaleUniversity. Shewasapostdoctoralfel-
lowattheAnxietyandTraumaticStressProgramatthePayneWhitneyClinicofNewYorkHospi-
tal–Cornell Medical Center.
KarestanC.Koenen,PhD,isanAssistantProfessorofSociety,HumanDevelopment,andHealth
andEpidemiologyattheHarvardSchoolofPublicHealth.Sheusesadevelopmentalapproachto
understanding the epidemiology of trauma exposure and stress-related mental disorders such as
PTSD and depression. Her research is funded by the National Institutes of Health, and she has
receivedtheChaimDanieliYoungProfessionalAwardfromtheInternationalSocietyforTraumatic
StressStudiesandtheRobins–GuzeYoungInvestigatorAwardfromtheAmericanPsychopatholog-
ical Association. Dr. Koenen is also an experienced clinician, specializing in empirically validated
treatments for PTSD. She received her BA from Wellesley College, her MA from Columbia Uni-
versity, and her PhD from Boston University.
vii
Acknowledgments
First,wewishtoacknowledgeourclients,whohaveinspireduswiththeircourageincom-
ing to treatment, confronting their traumas, and daring to hope for the possibility of a life
different from the one they have known. We wish to thank Stephanie Cherry, Sharon
Feeney, Tamar Gordon, Dawn Hughes, Karen Heffernan, Jill Levitt, and Chase Stovall-
McClough,whoasstudents,postdoctoralfellows,andcolleaguescontributedtothedevel-
opment of this treatment as long-term members of the research team.
We also thank Elissa Brown, Paul Frewen, Ruth Lanius, and Elizabeth Powers, who
read parts of the manuscript and gave feedback with humor, energy, and appreciation of
the task at hand. We wish to acknowlede innovators in psychotherapy intervention
research, from whom we have learned much. We thank Marsha Linehan, who developed
intervention strategies that have profoundly influenced our work and our effectiveness as
traumatherapists.WegivespecialthankstoEdnaFoa,whogavegenerouslyandalwaysof
herknowledgeandinsightsandwhohasservedasarolemodelinthescientificinquiryof
posttraumaticstressdisorderintervention.Withpleasureanddeepestgratitude,wethank
the pioneers in the field of complex trauma, who by their example and encouragement
have guided and inspired our efforts: John Briere, Christine Courtois, Judy Herman, and
Bessel van der Kolk.
Lastly, we would like to thank those individuals who have been especially important
in our professional development and personal growth: Susan and George Cohen, Diana
Fosha, Fran Grossman, Denise Hien, Nick Jollymore, Harold Koplewicz, Kathleen and
Austin Koenen, Alba Ludmer, Shaun Purcell, and Ron Taffel.
viii
Preface
WHAT IS THE INTERRUPTED LIFE?
Thereisanavalancheofdatathattellussomethingsurvivorsofabusealreadyknowthem-
selves: Functioning in day-to-day life is much harder for them than for those who have
experiencedasafeandsecurechildhood.Perhapslesswellknowntothemarethereasons
why. Throughout this book we highlight and specify ways in which childhood abuse can
derailthenormalcourseofdevelopmentanddeprivetheindividualofimportantlearning
experiences that foster healthy and effective life skills. These include basic and complex
skills such as the capacity for sustained attention, the capacity to express feelings effec-
tivelyandappropriately,thecapacitytouseemotionsasaguideforaction,andthecapac-
itytorelatewelltoothersandtoenjoyrelationships.Interventionsforchildrenandyouth
who have experienced abuse are sensitive to these consequences and include strategies
that repair and enrich emotional and social competencies, with the goal of realigning the
young client back on the normative trajectory of development.
But what of the adults who lived through an abusive childhood without help? Those
who come to treatment often express concern about long-standing emotion management
and relationship problems. And yet, there is no program or intervention that addresses
their concerns. Instead, the suffering of the adult survivor is typically organized by diag-
nostic status and symptom categories. The interpersonal and other difficulties are viewed
as secondary to evident symptomatology: If the depression or anxiety is resolved, these
other difficulties are expected to dissipate. The scientific community’s careful tracking of
the compromised social and emotional competencies caused by maltreatment ends with
studiesofteensandyoungadults.Thereisaremarkabledisconnectbetweentheobserva-
tionsmadebychildmentalhealthprofessionalsandtheclinicalworldthattreatstheadults
who were once abused children.
This book provides a treatment program that takes into account the long trajectory of
disadvantages experienced by many abuse survivors that precedes their arrival into the
therapist’soffice.Theconceptofthe“interruptedlife,”whichguidesthistreatment,refers
ix
x Preface
tothedisruptioncausedbyabusetoself-regulationandinterpersonalcapacitiesthatother-
wise would have been expected to develop. The treatment is intended to provide the sur-
vivors with emotional and social skills they did not have the opportunity to obtain due to
thediminishedpresenceofacompetent,caring,nurturingparentandtheburdenofman-
aging the abuse, often alone or in secrect. The first module of this treatment, Skills Train-
ing for Affective and Interpersonal Regulation (STAIR), has been explicitly developed to
generate and strengthen social and emotional resources for effective living.
Atreatmentfortraumawouldbeincompleteifitdidnotaddresstheequallyprofound
although more recognized problem of posttraumatic stress disorder (PTSD). PTSD symp-
toms and associated disturbances such as depression, dissociation, anger, and feelings of
shameandlossareindicatorsthatthereis“unfinishedbusiness”intheprocessingoftrau-
matic experiences. Traumatic events, by their very nature, overwhelm the individ-
ual’s capacity for understanding and analysis. The challenge to understanding is made
even greater because the emotions associated with the abuse—terror, humiliation, and
betrayal—are extremely painful and thus often avoided. Traumatic memories, when they
remain unprocessed, are expressed through intrusive memories and reexperiencing,
which interfere with the capacity to live meaningfully and fully in the present. Moreover,
this processing work is a prerequisite to the integration of such memories into one’s auto-
biographical narrative, the existence of which provides a coherent sense of self and one
thatiscontinuousacrosstime.Theinabilitytoexperienceoneselfascoherentandexisting
through time is another way in which life is “interrupted” for the trauma survivor.
NarrativeStoryTelling(NST)providesastructureandstrategyforapproaching,man-
aging,andorganizingtraumaticexperiencesthathavebeenunaddressedbutarestillquite
alive with emotional power. NST begins with the emotional processing of fear memories
using traditional imaginal exposure techniques (Chapter 6). However, this work is
extended in two ways. First, we have developed and systematically employed “con-
textualization”strategies,groundedinrecentmodelsofautobiographicalmemory,toorga-
nize and construct a “narrative of self” (Chapter 7). Second, through these strategies, the
client and therapist are able safely and effectively to explore and organize a sense of self
around two critical affective themes that often burden the abuse survivor: shame and
betrayal (Chapter 22) and loss and grief (Chapter 23).
Finally, the phrase “psychotherapy for the interrupted life” has a third meaning, one
thatalludestoaparticularhopefortheclient.Itrecognizesthatthemanagementandcon-
sequences of abuse create circumstances in which the gifts and talents an individual may
have had were irrelevant, unrecognized, or underdeveloped. In regenerating important
life skills and a coherent and revitalized sense of self, we hope that the clients can, in
essence, resume the realization of their hidden potential.
WHO CAN BENEFIT FROM THIS BOOK?
This book provides an evidence-based treatment for mental health providers who work
with survivors of childhood abuse. These survivors include women and men who have
experiencedsexualabuse,physicalabuse,andneglect.Thetreatmentwasoriginallydevel-