Introduction to Counselling Survivors of Interpersonal Trauma

Christiane Sanderson

• Publisher: Jessica Kingsley Publishers
• Year: 2009
• ISBN:
  9780857002136
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Victims of sexual and physical trauma can feel lost and disconnected from themselves and others. Christiane Sanderson's new book explains how counsellors can restore connection to self and others, and facilitate recovery within a safe and supportive therapeutic relationship.

To understand fully the harm caused by interpersonal trauma, professionals must first recognize its complex nature, and the psychological and emotional impact of exposure to control and terror. This book examines the therapeutic techniques and specific challenges faced by professionals when working with survivors of interpersonal trauma. The author explores issues such as safety and protection, the long-term effects of trauma and the importance of visiting past experiences and assessing their impact on the present.

This book is essential reading for counsellors, therapists, social workers, mental health professionals, health care professionals including GPs and midwives, legal professionals and all those working with survivors of interpersonal trauma such as sexual violence, child abuse, domestic abuse, elder abuse, institutional abuse and abuse by professionals

Part I

The Nature of Interpersonal Trauma and Clinical Practice

Chapter 1

What is Interpersonal Trauma?

The term “trauma” conjures up different meanings and understanding not just between health professionals but also among those who have experienced trauma. As many survivors of interpersonal abuse do not conceptualise their experiences as trauma, they are often not able to legitimise their experience, or name it as trauma, and thus are prevented from seeking appropriate professional help. In order to work with survivors who present with a history of interpersonal abuse, counsellors need to be clear about what constitutes interpersonal trauma and how this knowledge can be used effectively to understand the range of trauma-related symptoms presented by clients.

This chapter looks at the essential components of trauma and how different types of traumatic experience have been conceptualised, in particular the differences between single event trauma and multiple and repeated trauma. Its main focus is on what constitutes interpersonal trauma experienced within the context of a relationship, or perpetrated by someone known to the survivor. It is hoped that by understanding what is meant by interpersonal trauma counsellors will be able to locate survivors’ experiences and concomitant symptoms within a trauma framework.

Components of trauma

Commonly trauma is either understood in very narrow terms such as major natural or manmade disasters, or generalised to mean any form of “stressful experience” (Sanderson, 2006). Dictionaries often define trauma as “distress” and “disturbance”, whereas medical definitions emphathise “injury produced violently”. Psychiatric conceptualisations refer to psycho injury, especially that caused by emotional shock, for which the memory may be repressed or persistent, and that has lasting psychic effect.

The American Psychiatric Association (APA)’s Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM-IV-TR) (American Psychiatric Association, 2000) criteria for trauma leading to post-traumatic stress disorder (PTSD) is largely derived from symptoms seen in survivors of combat, natural or national disasters, or what could be denoted as impersonal trauma (Allen, 2001). The diagnostic criteria incorporates both an objective event and subjective response in that it requires the presence of an actual and threatened serious injury to the physical self accompanied by intense fear, helplessness, or horror. This implies that it is not just the event that is critical but also the enduring adverse response to the experience, as distinct from horrific events that are not accompanied by enduring adverse effects.

The focus on physical injury or threat, however, is considered to be too narrow by many clinicians (Allen, 2001) as it fails to include threat to psychological integrity which threatens to undermine self-structures and related mental capacities. Although the APA have a diagnostic caveat in the case of children which states that “for children sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury” this is currently not extended to adults experiencing unwanted sexual experiences such as rape, or sexual slavery, or domestic abuse.

The criteria used in DSM-IV-TR are thought by some researchers to be further limited by neglecting to specify the impact of pervasive and habitual unpredictability and lack of control, which is considered by some to be a core aspect of trauma (Foa, Zinbarg and Rothbaum, 1992). Control and predictability is critical for individuals to feel safe and secure, monitor danger and take appropriate steps to avoid or minimise danger. In the absence of predictability, controllability is compromised leading to increased arousal, heightened conditioned fear responses, numbing and avoidance (Allen, 2001). In addition, as heightened arousal activates primitive survival strategies and diverts energy to subcortical functions, the individual is unable to make sense of the experience and generate meaning, making it harder to process the trauma.

Spectrum of trauma

A limitation in the DSM-IV-TR formulation of trauma is that it does not capture the broad range and types of traumatic experiences. For instance, it does not distinguish between different types of trauma such as those caused by natural disasters, accidents, or acts of terrorism and trauma which consists of physical or psychological assault on an individual within an attachment relationship. To account for these variations in traumatic experiences, some researchers have proposed a spectrum of trauma to enhance clinicians’ understanding of impact and effects of trauma, symptomatology and potential treatment implications.

Allen (2001) proposes three main types of trauma: impersonal trauma, interpersonal trauma and attachment trauma. Impersonal trauma is characterised by manmade and natural disasters, interpersonal trauma by criminal assaults such as rape by a stranger, while attachment trauma refers to interfamilial abuse and child sexual abuse. Allen proposes that attachment trauma can have more pervasive effects compared with other types of trauma due to the presence of aversive dynamics such as the betrayal of trust, dependency needs, loss of bodily integrity, and inescapability.

In many respects, Allen’s attachment trauma echoes Pamela Freyd’s (1996) notion of “betrayal trauma” which is defined as trauma that occurs in relational contexts where a person violates role expectations of care and protection. The effect of such violations is the severing of human bonds and loss of important human connections.

While this continuum of trauma differentiates between different types of trauma, there may be overlap between each type such as car accidents (both impersonal and interpersonal) and acquaintance or date rape (interpersonal without a real established attachment). The main distinction used in this volume will be between impersonal trauma and interpersonal trauma.

A further crucial distinction that is not addressed in the DSM-IV-TR criteria for traumatic stressors is differentiating between single event trauma and multiple and repeated trauma. Impersonal trauma is usually associated with a single event, while interpersonal trauma commonly consists of a series of repeated traumatic experiences over prolonged periods of time. In addition, interpersonal trauma is characterised by multiple violations such as physical violence, sexual assault, emotional abuse and neglect.

To counterbalance these omissions in the classification criteria, Lenore Terr (1991) distinguishes between Type I trauma which is characterised by a single traumatic event, and Type II trauma which involves multiple, prolonged and repeated trauma. Commonly, Type II trauma is associated with much greater psychobiological disruption, including complex PTS reactions, denial, psychic numbing, self-hypnosis, dissociation, alternations between extreme passivity and outbursts of rage, and significant memory impairment.

Building upon these distinctions, Rothschild (2000) has further refined these categories to include Type IIA and Type IIB trauma, with Type IIB further subdivided into Type IIB (R) and Type IIB (nR). According to Rothschild (2000), Type IIA trauma consists of multiple traumas experienced by individuals who have benefited from relatively stable backgrounds, and thus have sufficient resources to separate individual traumatic events from one another. In Type IIB the multiple traumas are so overwhelming that the individual cannot separate one from another. The type of trauma most frequently associated with prolonged and repeated interpersonal trauma is Type IIB (R) in which the person had a stable upbringing but the complexity of traumatic experiences are so overwhelming that resilience is impaired, or Type IIB (nR) in which the individual has never developed resources for resilience. The latter is characteristic of those survivors of interpersonal abuse who have a history of childhood trauma such as physical or sexual abuse, and adult revictimisation.

Complex trauma

Perhaps the most field-tested revision of multiple and repeated trauma is Judith Herman’s (1992b) complex post-traumatic stress disorder, which aims to elaborate on the current DSM-IV-TR criteria for traumatic events, by highlighting significant differences in terms of impact and symptomatology between single event trauma and multiple and repeated trauma. Complex post-traumatic stress disorder aims to expand the current diagnostic concept and truly capture the complex symptomatology that follows prolonged and repeated trauma. This more inclusive conceptualisation was submitted for inclusion in DSM-IV-TR in 2000 as a separate, stand-alone category. While not adopted as a separate classification, it was designated under “disorders of extreme stress not otherwise specified” (DESNOS). As the need for specific formulations of complex trauma has gained wider recognition, it is hoped that the APA will adopt this new category in DSM-V due in 2012.

The revised ICD-10 Classification of Mental and Behavioural Disorders (ICD-10) (World Health Organisation, 2007) has taken into account both prolonged trauma and the delay or protracted responses to it in their category of PTSD: “… a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone…[that] may follow a chronic course over many years, with eventual transition to an enduring personality change.”

While complex post-traumatic stress disorder was originally conceptualised to understand the impact and symptoms of childhood trauma, it has ecological validity in understanding the impact of abuse in adulthood. This formulation incorporates the impact of a series of “blows”, or process of multiple, chronic and prolonged developmentally adverse traumatic events, such as sexual or physical abuse, war, or community violence committed in the absence of adequate emotional and social support. As it encompasses interpersonal, intrapersonal, biological and existential/spiritual consequences of repeated exposures to trauma, it is particularly apt in highlighting the symptoms seen in cases of habitual, repetitive and inescapable abuse in intimate relationships such as domestic abuse, elder abuse and sexual slavery, or those held in “captivity”, or in thrall to their abuser. As Herman (1992b) argues, “Survivors of prolonged abuse develop characteristic personality changes, including deformations of relatedness and identity...” which are not accounted for in current formulations of PTS responses, and yet are manifest in survivors of interpersonal abuse.

Developmental trauma disorder

To further understand the impact of repeated interpersonal abuse across developmental stages in children, the Complex Trauma Task Force for the National Child Traumatic Stress Network have conceptualised a new diagnosis, provisionally called developmental trauma disorder (van der Kolk et al., 2005). This formulation incorporates the features and impact of repeated and prolonged abuse through multiple or chronic exposure to one or more forms of interpersonal trauma such as abandonment, betrayal, physical and sexual assaults, threats to bodily integrity, coercive practices, emotional abuse and witnessing violence and death (van der Kolk et al., 2005). Developmental trauma disorder is most likely to occur when exposure to such trauma is accompanied by the subjective experience of rage, betrayal, fear, resignation, defeat, and/or shame.

It is proposed that repeated, multiple acts of abuse and trauma across critical developmental stages can lead to developmental derailments, such as complex disruptions to affect regulation, disturbed attachment patterns, rapid behavioural regressions and shifts in emotional distress. This is commonly accompanied by a loss of autonomous strivings, aggression against self and others, failure to achieve developmental competencies, loss of bodily regulation such as sleep, food and self-care, and altered schemas of the world. Hyperarousal and hypervigilance can lead to altered perceptions, anticipatory behaviour and traumatic expectations, multiple somatic problems from gastrointestinal distress to headaches, apparent lack of awareness of danger resulting in self-endangering behaviour, self-hatred and self-blame, and chronic feelings of ineffectiveness (van der Kolk et al., 2005).

Interpersonal trauma within attachment relationships

In response to clinical evidence, this book defines interpersonal trauma as prolonged and repeated exposure to chronic, multiple, and repeated abuse within relationships, which give rise to complex PTS symptoms. Such abuse is commonly committed by someone who is in a position of trust, or to whom the individual is attached, or upon whom the individual is dependent. Ubiquitous to interpersonal trauma is the abuse of power, use of coercion and control, the distortion of reality, and the dehumanisation of the victim. It is hoped that this definition will illuminate the impact of repeated violations, inescapable terror and inert surrender commonly seen in survivors of child abuse, child sexual abuse, and rape within intimate relationships, domestic abuse, elderly abuse, sexual slavery and abuse by professionals. Given the complex PTS symptoms, counsellors will need to direct specific therapeutic attention and focus to the dynamics of interpersonal trauma.

A significant characteristic of interpersonal trauma within relationships is that the violations are not always perceived as painful or life threatening, and frequently do not immediately evoke fear or helplessness. They may initially be experienced as confusing or distressing, rather than traumatic. The awareness of the betrayal and threat may come long after the experience has occurred as a result of later cognitive reappraisal of the event. This is commonly the case in child sexual abuse, sexual assault by partner or acquaintance, elder abuse and abuse by professionals. Usually it is only when the individual is in a place of safety, or when able to mentalise the experience, that the perception of betrayal of trust and relational bonds and the link to trauma can be made.

It is not until the person is able to understand the meaning of such violations that they can legitimise, and label it as abuse or trauma. This casts the survivor into an abyss of silence, where their subjective experience has to be hidden from self and others. Once cognitive reappraisal has occurred and there is recognition of the traumatising effects of such abuse, the individual may begin to manifest delayed complex PTS response, long after the events.

The repeated betrayal of trust within relationships accounts for such pervasive effects as fragmentation of self-structures, loss of self-agency and relational difficulties which are commonly found in survivors of interpersonal trauma. Research indicates that interpersonal trauma within attachment relationships is likely to have more devastating effects compared with other types of trauma as such experiences not only generate extreme distress but also undermine the mechanisms and capacity to regulate that distress (Allen, 2001; Fonagy, 1999; Fonagy and Target, 1997). Survivors of interpersonal abuse often lose the capacity for affect regulation to manage trauma symptoms and suffer a dual liability in not being able to seek comfort from their attachment figure, as (s)he is also the abuser. This reinforces the survivor’s terror and sense of aloneness as the very person who can alleviate the terror is also the source of that fear.

The severity of interpersonal trauma within attachment relationships will vary in intensity and symptomatology depending on each individual’s experience. In evaluating the extent of interpersonal trauma, and its impact, counsellors need to assess the level of dependency, the extent of coercion and control, intensity of traumatic bonding, the degree of violence experienced, the level of aggression and sadism encountered, and the frequency and duration of the abuse (Allen, 1997).

To fully understand the impact of interpersonal trauma and concomitant symptomatology, counsellors will need to familiarise themselves with the nature of interpersonal abuse, especially the use of deception, falsification of reality, and annihilation of the subjective self. The following chapter will look at the complex dynamics associated with interpersonal abuse that lead to traumatisation.

Summary

• As definitions of trauma vary enormously it is critical to have a mutual understanding between clinicians and their clients of what is meant by trauma so that traumatic experiences can be legitimised, and named.

• The DSM-IV-TR (2000) definition of trauma derived from combat, natural or national disasters, or impersonal trauma, emphasises the presence of an objective event that entails physical injury and the subjective experience of fear, helplessness and horror.

• This criterion is limited in not distinguishing between the impact and effects of impersonal and interpersonal trauma. It also does not account for significant differences seen in single event traumas and those associated with multiple, repeated and prolonged trauma.

• A number of revisions have been proposed including Type I and Type II trauma (Terr, 1991), Type IIA and Type IIB trauma (Rothschild, 2000), complex traumatic stress disorder (Herman, 1992a; 2006) and developmental trauma disorder (van der Kolk et al., 2005) to expand on current criteria.

• The 2007 revision of the ICD-10 Classification of Mental and Behavioural Disorders (World Health Organisation, 2007) in their classification of PTSD includes prolonged and repeated traumatic events, as well as delayed or protracted responses w...

Table of contents

• Cover
• Title
• Contents
• Acknowledgments
• Introduction
• Part I The Nature of Interpersonal Trauma and Clinical Practice
• Part II Spectrum of Interpersonal Abuse
• Part III Professional Issues