Treating women incest survivors: a bridge between "cumulative trauma" and "post-traumatic stress".

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Treating Women Incest Survivors Roberta Graziano DSW

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Assistnat Professor, Hunter College School of Social Work Published online: 26 Oct 2008.

To cite this article: Roberta Graziano DSW (1992) Treating Women Incest Survivors, Social Work in Health Care, 17:1, 69-85, DOI: 10.1300/J010v17n01_05 To link to this article: http://dx.doi.org/10.1300/ J010v17n01_05

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Treating Women Incest Survivors: A Bridge Between "Cumulative Trauma" and ''Post-Traumatic Stress" Roberta Graziano, DSW

ABSTRACT. While the concept of traumatic stress plays an intrinsic part in the diagnosis and treatment of adult incest survivors, the developmental framework within which the victimization has occurred may be overlooked. This paper presents a treatment model' that integrates theories of post-traumatic stress and early environ, mental trauma. A profile of women incest survivors is given and an overview of treatment strategies utilizing the above theories is dis-. cussed. It is now known that the sexual abuse of children is a more wide, spread phenomenon than was formerly believed. Adult survivors of incest and childhood sexual misuse have come forth in mowing numbers. some to "go public" in print and on TV talk shows &d oth& to seek treatment specifically geared to the psychological effects of the abuse experience. There have been many survivors of sexual abuse among the clients of social and health care agencies, but in the past they did not identify themselves as such, nor were specific interventions or programs generally available to treat them in most settings. At present, self-help groups, workshops, and referral services, focused on victims and survivors of sexual abuse and family violence, are becoming more available. In health settings, these clients may be treated in inpatient and outpatient psychiaRoberta Graziano is Assistant Professor, Hunter College School of Social Work. O

Social Work in Health Cue, Vol. 17(1) 1992 1992 by The Haworth Ress, Inc. All rights reserved.

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try units, detoxification and substance abuse services, gynecology and general medical clinics, among others, as well as in special programs such as rape crisis units. Many adult incest survivors also appear in community mental health clinics, family agencies, substance abuse programs and in private psychotherapy offices. As a result, clinical social workers in most of the settings mentioned above are now often faced with the task of recognizing and dealing with the symptoms of the adult who has been sexually abused as a child, even though the survivor does not always overtly identify or recognize them. Social workers have now become knowledgeable about the occurrence and extent of sexual abuse and its sequelae. However, the critical issue of the context within which the abuse has occurred is often overlooked. More specifically, the cumulative effect of the family and early childcaretaker experiences needs to be examined and addressed, along with the understanding of the effects of later traumatic sexual abuse events, in order for effective treatment to take place. This paper explores the continuing aftereffects of the traumatic events of sexual abuse and family violence on adult women, within the context of earlier, less observable "cumulative trauma." Relevant concepts from post-traumatic stress and object relations theory are reviewed, characteristics of the client population are discussed, and the application of these ideas to clinical social work treatment is illustrated

THEORIES OF TRAUMA Post-Traumatic Stress and Rehted Concepts The diagnostic entity of Post-Traumatic Stress Disorder, which can arise in response to " . . .a recognizable stressor that would evoke significant symptoms of distress in almost anyone" (APA, 1980), has several characteristic features. They include (1) the reexperiencing of elements of the traumatic event in dreams, intrusive and distressing images, and dissociative mental states, and (2) emotional constriction such as psychic numbing, loss of normal responsiveness and affect, and a decrease of interest or involvement in relationships and work. These intrusive and. numbing features may occur in cycles. Additional symptoms may include hyperalemess, sleep disturbance,survivor guilt, impaired memory, difficulty concentrating, avoidance of activities associated with the traumatic event, and worsening of symptoms when exposed to events associated with the traumatic event.


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In addition to describing a syndrome, the intrusive and numbing features also reflect "a dynamic process by which a survivor attempts to integrate a traumatic event into his or her self-structure" (Green, Wilson and Lindy, 1985). Briefly, this can be explained as a phenomenon of human cognition: the tendency to store psychological elements of a traumatic life event in active memory until they can be successfully assimilated into existing beliefs and expectations about the self and others. In the intrusive phase, the psychological elements break through into consciousness as unwanted, upsetting and uncontrolled images that pressure the individual to process them cognitively, but at the same time these images heighten anxiety. The numbing phase, which is seen as a defense against the breakthrough, serves to ward off the memories, reduce cognitive processing, and decrease anxiety. "Eventually, if working through occurs, the new external information is incorporated into the preexisting internal model and, gradually, information storage in active memory will terminate. . . . Until this working through has occurred, the individual can be viewed as experiencing psychic overload" (Green, Wilson and Lindy 1985, p. 56). If working through does not occur naturally, then treatment can assist the individual to assimilate the information about the traumatic event, thereby reducing the psychic overload by d i s h i n g the burden of information stored in active memory. Preexisting personality characteristics, related to prior stressful events, may make a person more susceptible to developing R S D . In investigating the effects of childhood incest, Donaldson and Gardner (1985), in their report of the work with their client population of adult women incest survivors, supported the idea that in many families where sexual abuse is occurring children experience other stressors beyond the incest, including distant or dysfunctional relationships between parents; distant, intrusive or role-reversed relationships between parent and child; poor ego boundaries between family members; poor family communication; poor sibling relationships;depressed-dependent mothers; alcoholic fathers; etc. In addition to the cvcle of intrusive thoughtsldenial the responses to k e -family and numbing typical of PTSD in stressors enumerated above may include fear and anxiety, guilt, shame, low self-esteem, sadness and depression, social isolation, diffkulty with intimate relationships, promiscuity, and substance abuse. Donaldson and Gardnei further speculated that the delayed PTSD may be more severe and long-lasting when the abuser "is not an anonymous rapist but someone presumed to be trustworthy and whose presence persists" @. 375); that is, when the stressor is part of the family. They comment further that the striking loneliness seen in their group members


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"may have arisen from deficient family trust at a critical developmental period." They found that group therapy within a framework that explained stress-response syndrome to their clients gave the women a tool for processing their information and facilitated recovery. A related model for understanding the impact of traumatic events on an individual focuses on the existence of "beliefs and exoectations (schemata) about the self and others, which both shape and are shaped b; their experience in the world" (McCann et al., 1985). Schemata in the areas of safety, trust, power, esteem, and intimacy are salient for victims of childhood sexual abuse, and develop in the order listed. The goal in treatment is to help the incest survivor use the cognitive processes of assimilation and accommodation to manage the discreaancv between the input from the current environment and-the ~elf-~rGecti;esystems of denial, dissociation, etc. which evolved in response to past traumatic events. These discussions of reactions to traumatically stressful events suggest that in order to understand any individual's response to the impact of the actual sexual abuse, it must be explored within the context of family events and relationships, which may date back to very early developmental experiences. It is helpful to draw upon certain concepts from the realm of objectrelations theory in understanding the repercussions of these experiences on the survivor. Curnulalive Trauma vs. 'Good-Enough' Mothering Two recent compilations (Levine, 1990; Kramer and Akhtar, 1991) suggest that a W ~ e theory d that explains the intrapsychic effects of childhood sexual abuse js yet to emerge, and that attempts to define and/or treat survivors using narrow parameters of one particular theory base may be misguided. The issue at hand is an explanation of the effect of certain developmental experiences. The concept of "cumulative trauma" was formulated by Khan (1963), in part as. an elaboration of Winnicott's many writings on the subject of the mother-infant relationship and the characteristics of the maternal environment which facilitated emotional growth. Khan discusses the mother's function as a "protective shield" which constitutes the child's "average expectable environment" (Hartmann, 1939) and argues that cumulative trauma is a result of the breaches in the mother's role as a protective shield over the whole course of the child's develop

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ment, from infancy to adolescenm-that is to say, in all those areas of experience where the child continues to need the mother as an auxiliary ego to support his immature and unstable egc-functions. . . . these breaches over the course of time and through the developmental process cumulate silently and invisibly. .. .They gradually get embedded in the specific traits of a given character structure. (Khan, 1963, pp. 46-47) It is the intrusion of the mother's personal needs and conflicts into the sphere of the infant's/child's needs that causes the mother to fail in her role as protective shield. Instances of this failure include (1) the intrusion of the mother's psychopathology, which W i c o t t (1949b, 1952a) has discussed as a failure of the good-enough holding environment; (2) loss or separation from mother; and (3) constitutional sensitivity or physical handicap of mother, or severe physical illness in child, which create an impossible demand (p. 51). Khan posits a fourth process, whereby the impingements of the mother's needs on the infant, and her ongoing failure to adapt to the child's needs, lead to some or all of the following consequences: (1) What might be viewed as a precocious development occurs, in which the child becomes especially responsive to the mother's needs and the integration of aggressive drives is unbalanced. (2) A "dissociation through which an archaic dependency bond is exploited on the one hand and a precipitate independence is asserted on the other" (p. 54) takes place. (3) Separation from mother is inhibited and a false sense of oneness with her exists. (4) An advanced ability to cathect inner and outer reality takes place, which disrupts the ego's synthetic function, its subjective awareness, and its experience as a coherent entity. (5) Development of the body ego is interfered with, resulting in an incapacity for "going on being" (Winnicott, 1958a) and also in a need for constant, hectic activity to avoid falling into a state of apathetic nonexistence. As regards treatment of cumulative trauma, Khan is concerned with reconstructing "the ecology of the childhood environment" which has led to the phenomena described above (Khan, 1964). Clues to the nature of this environment arise during interactions in treatment, in which patterns of very early experiences and object-involvements are reproduced. If we can tolerate this acting out and gradually enable the patient to perceive what he is making us see and register, then it becomes possible to enable him to tolerate that inner panic which compels him into this type of reenactment. . . When the patient, through our reconstructionsand interpretations, builds up enough confidence

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. . . (which is quite a different thing from blind and passionate transference . . . ) then he can begin to move to a deeper dependence. . . . @. 67) Using this frame of reference, the task in treatment would be to provide some of the functions of protective shield and auxiliary ego, or the properties of what Winnicott (1960b) called "good~nough" mothering, in terms of recognizing and adapting to the client's needs, rather than expecting the client to comply with the clinical social worker's needs (e.g., the need to interpret, to be neutral, to keep the client from regressing or being dependent, etc.). To do this means providing "the environmental condition of holding" ( W i c o t t , 1960a) and tolerating dependence. The "holding" often takes the form of being sufficiently attuned to the client that it is possible to convey in words, at the appropriate moment, "something that shows that the worker knows and understands the deepest anxiety that is being experienced, or that is waiting to be experienced." Occasionally, says Winnicott, holding may take a physical form, when verbal soothing is insufficient. The "dependence" is a sign that the client has risked regressing to a very vulnerable position where the greatest fear is that the worker will be unable to believe in "the reality and intensity of the patient's anxiety, a fear of disintegration, or of annihilation" (Winnicott, 1963, p. 240). Though Khan discusses the concept of cumulative trauma within the context of what is otherwise thought of as a "normal" family environment, it seems obvious that in a family where the parenting figures display the symptoms and relationships discussed in the previous section on post-traumatic stress, the depth and duration of the breaches or failures in the function of protective shield are s i ~ i c a n t l ymore intense, and early development is affected in such a way as to eventuate in a more acute response to later stressful incidents, necessitating a treatment a p proach that takes into account concepts of both cumulative stress and post-traumatic stress reactions. CHARACTERISTICS OF ADULT INCEST SURVNORS

Sgroi and Bunk (1988) define the adult s w i v o r of childhood sexual abuse as "a person who believes that he or she was exploited or abused by the person who induced h i or her to cooperate with interactive sexual behaviors. . . . The implicit premise is that these early sexual experiences were emotionally damaging to the individual in some way, hence


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the notion that the adult has survived a traumatic experience of childhood" @. 37). A contrasting view of "survival" is the outcome of a process which begins with the experience of victimization and which deals with the transformation of feelings of helplessness and powerlessness into feelings of strength (Rieker and Cannen, 1986). Approximately 20% of all adult women are believed to have been sexually abused before the age of 18 (Courtois, 1988, p. 16). They have had experiences along a continuum which ranges from exhibitionism through molestation to forceful rape or assault. It has been thought that up to 97% of the offenders are male, and 75 to 92% are known to the child; up to one-half (or more, by some estimates) are family members, frequently parents or parent-substitutes. In the vast majority of cases, sexual abuse has taken place repeatedly, often over a period of years (Conte and Berliner, 1981; Elwell, 1979). Survivors of childhood sexual victimization may suffer throughout their lives from difficulties such as depression, marital problems (including abusive spouses), substance abuse, sexual dysfunction, suicidal ideation, low self-esteem, and feelings of shame, guilt, anger and frustration, anxiety, social isolation, etc. Many survivors may also exhibit physical symptoms or syndromes, sometimes multiple in nature, which may not be immediately traceable to the childhood abuse. Sgroi and Bunk (1988) report two distinct patterns of adult survivors who present themselves for treatment. Clients who come to clinical attention at an early age (sixteen to twenty-five) usually have a history of substance abuse, acute psychotic reactions, self-mutilating behaviors, delinquency, teenage prostitution, running away, eating disorders, suicide attempts, or a combination of these symptoms. "In nearly all these cases, the individuals have a history of experiencing more than one type of child maltreatment: that is, childhood sexual abuse in combination with physical abuse, neglect, or emotional abuse. It is also usual for the person to have a history of being raised by at least one and sometimes two or more impaired parent figures or caretakers (e.g., parenting by persons with a chemical dependency, thought disorder, criminal lifestyle, or the like)" (p. 150). By contrast, the adult survivor who presents for treatment later in life (late twenties, thirties, or early forties) is described as likely to appear better put-together: more educated, successful at work, likely to be married and the parent of children who appear well-adjusted, and quite often having already had some experience of therapy, usually for another complaint (e.g., depression, anxiety, somatic complaints, low sexual desire) which did not prevent the survivor from functioning reasonably successfully.

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THE PRESENT STUDY

Most of the thirty-three women incest survivors treated by the author do not fit into these patterns; rather, their histories are similar to Sgroi and Bunk's "early presenters," but the age at which they sought treatment for the sexual abuse issues ranged from twentyeight to sixty-nine. The sample consists of all the women who reported childhood sexual abuse as an issue either at intake or during the course of treatment. The average age at which the last molestation occurred was 12.7; duration of molestation averaged 5.1 years. In addition to the incest, which had its onset anywhere from pre-school age to age eight or nine, and which lasted, for some women, into their teens, almost all have a history of family violence, including severe physical abuse, spouse battering between their parents, emotional torment, physical and emotional neglect, and/or parental alcoholism. Thus, the women are "late" in getting help for problems resulting from early, multiple, and severe abuse and neglect. Despite the family chaos, only one woman had a parent who had been hospitalized for suicidal depression; none had parents who had been jailed; severe poverty was not in evidence. This may, of course, bespeak societal ignorance or indifference to family violence, or successful secretkeeping by the family, rather than the absence of gross psychopathology! Most come from intact workingar middleclass families, are not college graduates, and are working at jobs below their level of training or abilities, if working at all. Most are not currently married; if married, their relationships are often problematic. A significant number of these women are recovering substance abusers, have a history of eating disorders, have made suicide attempts or gestures, and/or have been psychiatrically hospitalized. Several have had prior diagnoses of schizophrenia (chronic and/or paranoid), borderline personality disorder, or major depression. Over the past ten years, they have been seen either in the outpatient mental health clinic of a voluntary hospital, where they were part of a general caseload, or in a low-fee general private practice of clinical social work psychotherapy. The average length of time in treatment is approximately three years, though the range is from six months to more than four years; about half were in treatment for two years or less. Less than half of these women were sexually abused by a father, stepfather, or father-substitute.The majority were victimized by another family member (sister, brother, grandmother, uncle, mother, cousin), a friend of the family, or a caretaker (foster brother; religious personnel in orphanage; childcare worker). Some of the women had been abused by more than one person in childhood; some had been raped as adolescents or adults, after

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being victimized as children; some had had physically and sexually abusive marriages.


IMPLICATIONS FOR CLINICAL SOCIAL WORK TREATMENT When a woman with a background similar to that outlined above enters treatment, she brings with her a burden of suffering, a deep-seated and often well-justified mistrust, and (perhaps) a modicum of hope. She is accustomed to being not only abused and neglected, but disbelieved, disconfmed, and often disavowed by those who, in more normal families, would be protective and supportive. Consequently, she has little experience of being believed or cared for in a consistent way, despite her needs. In her own mind (and, often, in the mind of the therapist), the client is viewed as an incest survivor, or suffering from stress, or depressed, or anxious and panicky; from Khan's perspective, she is suffering from cumulative trauma. If we look at the symptoms reported by the individual in terms of the relationship of the incest experience to PTSD, speculate about the nature of the schemata developed as a result of the experience of incest and related family violence, add it to that of the outcome of cumulative trauma, and apply the total result to the treatment setting, we may have a beginning idea of what we and the client face. To put it another way, if a woman's schemata in the areas of safety, trust, power, esteem, and intimacy are formed as a result of both early cumulative trauma and later post-traumatic stress, then the latter (icest plus abuse and/or neglect) serve to reinforce earlier, already-formed schemata which have become integrated into the individual's personality and are therefore more likely to be much harder to "undo" than those we might encounter in an individual who had experienced a single traumatic event (e.g., rape) without a prior traumatic history. If we believe that issues of safety and trust are among the earliest areas where the individual develops internal beliefs and expectations, and we h o w that many of the women we see have had impaired, unsafe and untrustworthy early relationships with caregivers, then the baseline for treatment is the establishment of a "holding" environment. This requires that the social worker be extremely responsive to the client, proceeding slowly due to the client's difficulty in feeling safe or in trusting. Many incest survivors at fust present themselves in an $fectless, "frozen" state, discussing or describing their experiences in a monotone


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and remaining distant and withdrawn, often unable to make eye contact. Their terror of getting in touch with their feelings and/or their fear of being overwhelmed by them may require a period of experiencing the worker as a quiet, soothing, non-intrusive, yet empathic and engaged presence who is accepting of their difficulty in trusting and believes that what they say is true. The client's behavior and manner in the initial sessions can give important clues if the worker is able to "hear with her eyes": that is, to note discrepancies between content and affect, keep track of body language, etc. As mentioned above, after the client becomes somewhat more comfortable, "holding" may also include actual touch, within certain parameters: that it be nonsexual, and recognized by both client and worker as such; that the client request it (though the worker might note that the client looks like she could use someone to hold her hand or could use a hug); that the client be able to let the work, er kndw how the touch affects her. The worker must be aware that elements of early relationships are constantly being reactivated in the treatment situation, and be alert to shifting affects and expressions on the part of the client, often in response to seemingly innocuous activities on the worker's part: Ella's mother was sent to a state hospital, after she tried to commit suicide when Ella was two and a half. For a while, Ella and her siblings were cared for by an aunt who had a large family of her own. When Ella was five, she and her siblings were sent to a large religious childcare institution, where they were separated by age and sex. From the ages of five to twelve, Ella was beaten, sexually abused and subjected to sadistic punishments by the religious personnel. Later, she became a nurse and worked successfully for many years. However, marriage to a man who proved to be abusive reactivated many of her early issues. This situation was further complicated when he became comatose during surgery. Ella sought treatment about six months after her husband's coma had begun. She was actively suicidal and was hospitalized briefly. After her discharge, we resumed treatment. She could barely speak, kept her head down, constantly changed the subject, no matter what it was, and appeared territied. On several occasions, she fainted in my office, either in response to a question I had asked before (such as some inquiry as to her husband's status, which had not previously elicited such a dramatic response), or with no discernible slimulus. It took two years for her to let me know that at first, she was constantly having flashbacks while in my office, seeing an abusive


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religious person there instead of me. The flashbacks to horcfi memories of physical and sexual abuse have continued intermittently, especially at points where Ella has made significant gains (e.g., rehuning to college; becoming involved in a relationship). It has become clear to Ella that holding my hand is extremely helpful in enabling her to "come back" from a painful and frightening state. Clearly, one of the first things to listen for is family history and dynamics. An effective way of getting at these is through the use of a genogram. If the client is enlisted in helping the therapist to construct a genogram during the fust few sessions, much information may emerge that might otherwise have remained hidden: Cathy, in her late 30s, had recently been hospitalized for severe "hallucinations" (really flashbacks), and had been diagnosed as "chronic paranoid schizophrenic" despite the absence of any previous psychotic symptoms. The doctor who gave her the diagnostic label also refused to listen to any talk about incest, attributing it to her "schizophrenia." After discharge. Cathy sought adjunctive treatment for ongoing anxiety and depression related to childhood sexual abuse by two older brothers that had lasted from the time she was 5 years old until well into her teens. When Cathy began working on the genogram, she commented, "I come from a long line of axe-murderers." Though this was a joke, it did foreshadow our diswvery of a gender-specific pattern of intergenerationalabuse and violence in her family that has endured for at least four generations. Use of a genogram may also bring to the surface patterns of family abuse (sexual and otherwise) that were not presenting problems, as a sizeable proportion of incest survivors do not immediately come forth with these issues in treatment. When such a pattern begins to emerge in the history of a client who has not mentioned family violence, it is wise to go slowly, as the premature "discovery" of such family secrets may be enough to precipitate a flight from therapy. When a sense of commitment to treatment has begun to be established, it may be time to look at the issue of whether there is really enough time in the therapy situation for trust to unfold; that is, it may take a long time for the client to get to the point, to feel wmfortable enough to say what is on her mind. Given the usual practice of once-a-week, hour-or-less sessions in mental health clinics, this may pose a problem. One useful

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remedy is increasing the length of the session. Spending two hours, once a week, with a person who is slow to "open up" may be more effective than shorter but more frequent sessions:


As Cathy remarked, after we began to use longer sessions, "I used

to just begin to get comfortable and then we had to stop. In one hour, you kind of come in, say hello, talk about the everyday uaimportant stuff, and then just as you begin to relax and think, well now, it's safe here, I can start to talk about what's really on my mind, it's time to stop. Then all the ten walls go up again, and it takes a long time the next time for them to go down, and it's the same all over again" An important issue for survivors of incest and other traumatic abuse is that of dissociation, a phenomenon not uncommon in those with PTSD. However, the tendency to dissociate (and to split objects, and utilize displacement and projection as important defenses) is also traceable to earlier cumulative trauma, intensified by the later sexual and other family abuse. It is indeed important to point out to the survivor that dissociation was an important means of survival, as it enabled her to protect herself from overwhelming emotions and physical sensations, and that anybody faced with the situation that she experienced would likely have done the same. However, it is equally critical to recognize that splitting and dissociation are likely to be part of the client's character structure, and the manifestations of these processes are likely to occur in many other arenas besides those related to sexual abuse. One of these manifestations may be idealization of the worker; another may be a seeming inability to even recognize anger at the abuser, with concomitant displacement of rage onto a relatively innocent person. Yet another indication of dissociation may be the existence of various "parts" or "characters" within the survivor. Usually, at least one of these characters is a "little girl." (When taken to extreme, these characters are completely dissociated from one another, as in multiple personality disorder, a phenomenon not seen in this sample of clients.)

Dottie's father had sexually molested her since she was about three, when he would take baths with her. He was also subject to terrifying rages, during which he would beat Dottie and her sister, break furniture and doors, and appear completely out of control. On one occasion, he threw D. against a wall, fracturing her coccyx. Her mother was either "not there" because of her addiction to barbitu-


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rates, or tried to get D. to "understand" that her father had had a "hard life." D. started to drink at about the age of nine to numb her feelings; her adolescence and young adult years were characterized by a number of extremely dangerous relationships with men who raped her and/or were physically menacing. D. entered a twelve-step program in her early twenties and has remained abstinent for ten years. Her marriage of six years is frequently disrupted by her violent verbal outbursts against her adolescent stepson. The "Rational Dottie" part of her is aware that he has done nothing in reality to merit the murderous feelings that she has toward him (which she expresses only to her husband, in the stepson's absence). At the same time, the "Sergeant," or protector, sees the stepson as a threat to her existence, and the "Little Girl" resents the attention that D's husband pays the stepson and is also fearful that inappropriate sexual behavior is occurring between them. Dottie has also been unable, until recently, to feel any anger toward her father, though the "Rational D." part of her acknowledges that he, not the stepson, was indeed the abuser and the threat. She has also had great difficulty in expressing any negative feelings toward her mother, whom she still idealizes and feels a need to get close to. The "Rational D." part recognizes that the mother did not protect her and indeed participated in the physical and emotional abuse, but the "Little Girl" still needs to see the mother as perfect and wonderful. Lately, Dottie has begun to talk about poetry she wrote as a child, in which she created the character of "Filthy Gutter-man," an alien, comic-book villain, who didn't belong in the family. She has also, with some encouragement, begun to have internal dialogues between "Rational D.," the "Sergeant," and the "Little Girl," which have helped to defuse the rageful outbursts against her stepson. Dissociation, in addition to its psychological and behavioral manifestations, may also take the form of somatic symptoms which may emerge when the client begins to talk about the earlier abuse. Dottie, whose father had insisted that she be his flamenco-dancing partner as an adolesr cent, forcing her to perform in unsuitable circumstances, regardless of fatigue or pain, was barely able to walk due to knee and ankle problems, which surfaced when she began to examine the abuse issues. Ella, who had been repeatedly hit in the face and on the side of the head by childcare workers and religious personnel in the orphanage, had constant ear infections and sinus problems, for which she underwent a number of


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medical procedures during the period when she was struggling with disclosing the details of the abuse. Cathy was asthmatic, suffered from chronic bronchitis and frequent pneumonia, and had a host of gynecological problems, all seemingly related to the abuse; she had surgery for an intractable hiatus hernia during a period in therapy when she disclosed her revulsion at the abuse and at her own body, as well as hopelessness at the completely unsupportive and violent nature of her family. Though all three women had had many encounters with medical services around these same problems before beginning therapy, none of them had made the connection with the abuse, nor had any medical personnel investigated the etiology of their physical complaints. Further, their pattern of recognizing and attending to their bodily signals was to ignore or deny them until they reached crisis point, and then to seek emergency help. Issues of trust and mistrust continue to appear in treatment, coexisting and alternating with idealization and, perhaps, devaluation of the worker (though the devaluation seems less frequent). It is important to allow these issues to endure, without falling into believing the idealized version of rescuer or healer that is often projected into the worker. Along with these issues, difficulties in intimacy will continue to surface, with a p r e cess of distancing and closeness gradually evolving into a more balanced perception over time. As part of the treatment strategy for this population, it is important to supplement the individual therapy relationship (which tends to be long, term, intense, and, periodically, extremely dependent) with a group experience. The group can be either a self-help group, such as Survivors of Incest Anonymous, or a therapy group specifically for survivors of sexual abuse. Being able to meet other women who have had similar experienc; es, and to hear about the traumatic events, identify with the feelings, and even express their own, provides elements that cannot be supplied in individual treatment. The group experience can be relatively short-term and provides meaningful social support, which is often significantly absent in other areas of the client's life. Cathy, Dottie and Ella were all members, for a period of about nine months, of a weekly group. In addition to information and discussion about post-traumatic stress, the group members had the opportunity to tell their stories to an audience which they came to believe truly understood them because they shared a common experience of family violence and chaos. They were also able to recognize, in one another, instances of "tuning out" or dissociation in the sessions, and would gently bring the person back to the present, inquire as to what had happened, and help the group member to become


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grounded in reality. The group members' support of one another extended beyond the office: two of them had surgery during the lifetime of the group, and the other group members brought the group meeting to the hospital, in one instance, and to the member's home, in another, so as to reduce the fear and isolation of the affected members. Finally, the author believes that work with this population sometimes involves other than office visits. This position has taken the author to such places as the basement of Cathy's mother's house, where the original sexual abuse by her brothers had taken place; to hospitals, to visit clients who have had surgery and who have no support system to help them through their flashbacks of abandonment and abuse; to the wake of a client's mother, where the extended abusive family members, and possibly the abusers, would be present; to AA anniversaries, in celebration of a client's continuing sobriety; and to a state hearing to restore Ella's nursing license (which had been taken away years before due to use of controlled substances on the job), where the concept of PTSD and its relationship to Ella's behavior were explained.

SUMMARY As this report suggests, and at least one study has implied (Donaldson and Gardner, 1985), adult survivors of childhood sexual abuse may bring with them more than the symptoms of Post-Traumatic Stress disorder. In some cases, they carry a legacy of early physical and emotional abuse, neglect, and family violence which has affected their development from the very beginning, resulting in both physical and emotional sequelae. Consequently, they may appear not necessarily for outpatient psychotherapy related to the abuse, but in a variety of inpatient and outpatient medical, psychiatric, substance abuse, and community settings. Clearly, not all of these places provide long-term treatment. However, if workers are sensitized to the issues these clients are struggling with, referrals can be made, after focused short-term work, to appropriate sources, such as victim service programs, or to clinical social workers who have a special interest in this population. In addition, new resources, such as support groups, can be made available within a variety of agency settings. Working with this population can be both challenging and gratifying. The challenge is to develop effective treatment strategies, which may mean modifying the "traditional" model of out-patient therapy in a number of ways, continually utilizing pertinent theories and new research

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findings from various disciplines, while at the same time reaffirming one's grounding in clinical social work The gratification comes from the growth and strength seen in our clients when they are helped effectively.


REFERENCES American Psychiahic Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, D.C: Author. Conte, J.R. and Berliner, L. (1981). Sexual abuse of children: Implications for practice. Social Casework, 62(10), 601-606. Courtois, C. (1988).Healing the incest wound: Adult survivors in therapy. New York: W.W. Norton & Company. Donaldson, M.A. and Gardner,-R. (1985). Diagnosis and treatment of traumatic stress among women after childhood incest In C.R. Figley (Ed), Trauma and its wake. New York: Bmer/Mazel. Elwell, M.E. (1979).Sexually assaulted children and their families. Social Casework. 60(4), 227-US. Green, B.L., Wilson, J.P. and L i d y , J.D. (1985).Conceptualizingpost-traumatic stress disorder: A psychosocial framework. In C R. Figley (Ed.), Trauma and its wake. New Yoxk Brunner/Mazel. Hartmann, H. (1939).Ego psychology and the problem of adaptation. (English translation. 1958). New York: International Universities Press. Khan, M. (1963). The concept of cumulative trauma In Theprivacy of the self. New York: International Universities F'ress, 1974. (1964).Egodistortion, cumulative trauma and the role of reconstruction in the analytic situation. In The Privacy of the self. New York: International Universities Ress, 1974. Kramer, S, and Akhtar, S., Eds. (1991). The trauma of transgression: Psychotherapy of incest victim. Northvale, NJ.: Jason Aronson. Levine, H.B. (1990).Adult analysis and childhood sexual abuse. Hillsdale, N.J.: The Analytic F'ress. McCann, L., Pearlman, L.A., Sakheirn, D. and Abrahamson, D.J. (1988).Assessment and treatment of the adult survivor of childhood sexual abuse within a schema framework In S. Sgroi (Ed-), Vulnerablepopulations: Evaluation and treatment of sexually abused children and adult survivors. Vol. I. Lexington, M A : Lexington Books. Rieker, P. and Carmen, E. (1986). The victim-to-patient process: The disc o n h a t i o n and transformation of abuse. American Journal of Orthopsychiatry. 56(3), 360-370. Sgroi, S. and Bunk, B. (1988). A clinical approach to adult survivors of child sexual abuse. In S. Sgroi (Ed.), Vulnerablepopulations: Evaluation and treatment of sexually abused children and adult survivors. Vol. I. Lexington, MA: Lexington Books.

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W i c o t t , D.W.(1949a). The ordinary devoted mother and her baby. In The child and the family. London: Tavistock (1957a). (1952a). Psychoses and child care. In Collected papers: Through paediatrics to psycho-analysis. London: Tavistock (1958). (1958a). The capacity to be alone. In The maturational processes and the facilitating environment. New York: International Universities Ress (1965). (1960a). The theory of the parent-infant relationship. In The mafurationa1 processes and the facilitating environment. New York: International Universities Press (1965). (1960b). Ego distortion in terms of true and false self. In The mafurational processes and the facilitating environment. New Ymk: International Universities Press (1965). (1963b). Psychiatric disorder in terms of infantilematurational processes. In The maturational processes and the facilitating environntent. New York: International Universities Ress (1965).


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"Negative symptoms": a cumulative trauma stress disorder?

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