A LONG AND WINDING ROAD
For most victims of child sexual abuse, the suffering does not end with disclosure or when a child welfare agency steps in or criminal proceedings begin. In fact, it sometimes gets worse before it gets better. Unfortunately, however, victims and those who care for them often unrealistically expect the child to be free of the pain caused by the abuse once the actual abuse ends. Youngsters we treat frequently don’t even recognize that they are continuing to experience acute and prolonged distress related to their abuse, saying that they “just wanted this to be over . . . to not affect me anymore.” Sometimes they also view acknowledging any ongoing distress as letting the perpetrator “win.” Many youth, therefore, like Kayla, continue to at least initially suffer in silence, without access to the help they need to minimize the long-term damage of childhood abuse. They may deny the lower-level symptoms they are experiencing, only to have their distress escalate when they find they can no longer white-knuckle their way to recovery.
From all outward appearances, Kayla was competent enough to return to judo practice and the daily routines of her new life in Boston. On the inside, however, she was falling apart, the 4 years of sexual abuse continuing to take an extensive toll on her thoughts, moods, beliefs, and aspirations. While friends and family had hoped that Daniel’s arrest would be a watershed in Kayla’s life, she knew personally while standing in court at one of the preliminary hearings that her demons would not be swept away that easily:
The very first one, right before I moved to Boston—the restraining-order hearing—was the worst. Daniel came to court, and they asked me to come up and explain why I wanted a restraining order and all that. And his attorney starts cross-examining me, basically, at the restraining-order hearing, and saying, “Well, how old were you when you went on this trip?” So he was like, “So you were 16, so you were old enough to know. Would you say you were old enough to know better?” And so I was like “Uh, well . . . ” I started crying. The judge had to stop him, and then she basically just said to him, “This is not about what he’s being charged with; this is about staying away from her, so you have no business bringing that into the courthouse.” But he was, right now, and the guy was trying to rip into me. And then the only other time I saw Daniel was at the sentencing.
Given that victims often struggle with their own confusion about why they were “chosen” by the perpetrator, about whether their victimization was their own fault, and in some cases have remained silent for a period of time about their abuse, how they are treated and responded to by parents, friends, agencies, and courts can have a critical impact on their short-term well-being and longer-term recovery.
So can many other factors. Kayla didn’t want to be in Boston, living with strangers. She didn’t even want to train anymore. Day and night, Kayla would think about what was happening to Daniel and how this was all her fault. She swung between the depths of regret and shame and bouts of relief, and these mood swings were hard for her to predict and understand and even harder to talk about. Again she took to writing about her hidden, ongoing emotional pain and conflict:
April 15, 2008 (age 17)
Dear God,
Hi. How are you, Lord? I’m all right, although I don’t still know if I did that right thing or the wrong thing . . .
Did Daniel really love me?
I put him in prison; is that the right thing? How can I ever know if it was really my fault or not . . . I would appreciate your help with this . . .
Love Always,
Kayla
Withstanding sexual abuse at the hands of someone who is known and trusted leaves children confused, demoralized, and frequently unable to fully function in their daily lives. For Kayla, it took the urging and support of her ever-vigilant new coaches, family, and teammates in Boston for her to accept that she needed professional help to deal with her enduring symptoms of what was later diagnosed as PTSD and depression. Only with such help, her coaches realized, would she be freed from the tangled web of associations between her abuse at Daniel’s hands and her beloved sport of judo and be able to reclaim her dreams. What to expect along the victim’s path to recovery and how to recognize the signs that professional help and support from family and close friends are needed is an important issue and the topic of this chapter.
FEELING WORSE AT FIRST
As mentioned in Chapter 4, sexual abuse victims often tell us that their “new normal” after disclosure is in some ways initially worse in that they now have many more adults involved in directing their life and they have to contend with a loss of privacy and sometimes unwanted ramifications for their abuser. Prolonged abuse can create a constellation of symptoms in children, such as the following, that you may notice for the first time after disclosure, precisely because children often feel more instead of less distressed at this juncture:
It’s not surprising that repeated victimization leaves scars. What surprises many parents, law enforcement, and child welfare personnel is that the event that ends the abuse itself does not bring instant relief from the emotional damage. If you see the preceding signs from your child following disclosure, seriously consider getting professional help for the child, as discussed in Chapter 6. Meanwhile, continue to offer understanding and support.
KEEP THE OPEN DIALOGUE GOING
Even though caregivers and involved authorities alike often take actions at this time that they assume will make the victim feel better, these interventions can miss their mark because they don’t fully address the depth and scope of the victim’s psychological distress. Yes, the child needs your comfort and protection, but she also may, counter-intuitively, show anxiety about whether her abuser will be all right. Certainly, a child who has been abused needs to feel your understanding and empathy, but she may above all need you to ask how she’s feeling, and not assume you know. An abused child might need your reassurance that you know she’s telling the truth and then abruptly burst out with self-blame and guilt when you offer it. What is most helpful in this situation—even when children are believed and the adults and agencies in their environment respond with support and empathy—is to keep an open dialogue going that allows them to talk about the complexities of what they are experiencing.
With child victims of sexual abuse, the most important response after disclosure is to allow them to talk openly about the depth and complexity of their emotional experiences. This often involves helping them find an experienced therapist or counselor whom they can speak to candidly and who can help them through the complex postdisclosure period.
RECOGNIZE THE CHILD’S NEED TO ADJUST TO A HUGE SHIFT IN HER DAILY REALITY
We talked about the need to deal with a new normal in Chapter 4. Child and adolescent victims have already suffered once from an abuse of power and frequently misplaced trust in an adult. Therefore, even when the adults they disclose to respond in ways that make sense and may even be mandated by law, children need time to adjust to their rapidly changing reality. Before disclosure, the abuser was the central focus of the child’s fears, longings, and actions. But from Feeling helpless and confused by the new realities of postdisclosure life can elicit distressing reminders of the helplessness of being victimized. the minute of disclosure the abuser’s place in the victim’s life and their access to one another has typically changed forever. And for the victim, anything that renders her helpless and confused can stir up distressing reminders of the original victimization. In other words, even when the immediate response to a disclosure of abuse is handled as thoughtfully and compassionately as possible, many youngsters will continue to have difficulties as they begin the challenging process of coming to terms with all they have been through and what they have lost.
Research has long shown that recovery can be slow and follow a winding path:
KNOW THAT TRAUMA SYMPTOMS MAY BE SIMMERING UNDER THE SURFACE
As the research evidence shows, not all abused children feel traumatized by the disclosure process. But that doesn’t mean they aren’t still struggling emotionally. After disclosure, many children struggle with PTSD and other trauma-related symptoms that often, along with the abuse itself, have remained underground for a significant period of time. Kayla remembers that it took months once she was in Boston for her to stop crying and to recapture her determination to sort through the myriad complicated emotional reactions from the abuse itself without resorting to self-destructive thoughts and behaviors. Particularly when there have been multiple incidents of abuse by a trusted adult, victims tend to develop a host of trauma-related beliefs and feelings that are difficult to shake, such as those described previously.
Kayla’s journals from the time immediately before her revelation show that her psychological distress was escalating, but of course it was kept hidden from others around her. This can make it difficult for parents and other adults to perceive the depth of the distress that may emerge after disclosure, which is why they need to anticipate it. As the journal entries immediately following her 16th birthday reveal, Kayla’s thoughts of suicide and feelings of depression had become a mainstay of her existence, leading up to her disclosing the abuse later that year:
July 6, 2006 (age 16)
Dear God,
Hi. It’s me. How are you? As of right now I’m all right. I’m on my way to San Jose, California, for the Junior Olympics. I’m 70 kg, now my weight is good.
Well, I just finished reading all of my old entries, and it seems that not a lot has changed. I’m still depressed if not more than ever. I still think about killing myself and have almost acted on it several times. I cut myself. It wasn’t for the first time and it probably won’t be the last.
I wonder if other people feel like this. Like an overwhelming sadness that runs deep in their hearts, like no matter what you do it will always be there.
I have felt suicidal for little over a year now and I wonder if I started acting on it now where will I be in another year’s time? Unable to write you? How long must this go on?
I’m tired of pretending like I’m happy. There’re many people I love and who I know love me.
God, for some reason it feels like the love will never be able to touch the sadness inside of me. And it scares me.
Am I supposed to live life feeling this way because, if I am, I can’t. Please help me conquer my demons. They wake me in the night and haunt me in the day. Please.
Love Always,
Kayla
PAY ATTENTION WHEN SYMPTOMS DO SHOW THROUGH THE VENEER
It’s wise to gently ask your teen about how she is feeling even if she is keeping the symptoms of PTSD beneath the surface. This is when the open dialogue becomes so vital. This does not mean nagging your child or insisting she is distressed when, Be open and curious rather than making assumptions about how your child is feeling, but observe closely. in fact, a proportion of children do report feeling better almost immediately following the revelation of their abuse. The guideline is to remain interested and curious about how the child is responding and let her know you understand and expect that she may be continuing to struggle in the aftermath of breaking her silence. You can also offer to take the teen to talk to a professional in the field if the teen is unwilling to talk with you at all; remember that we as professionals can probe in a way that parents cannot based on our cumulative experience. So, for example, in our practices we often talk with teens about the “typical” reactions we see from others in their situation, allowing them to feel less isolated and alone in their own responses.
What we hear most frequently from the abused youngsters we work with is that they feel distressed, confused, and desperate for relief both before and after their silence is broken. Kayla’s description of her nightmares, suicidal thoughts, and self-loathing highlights how these symptoms went largely unreported and unrecognized, which meant they could not be addressed:
To this day I still have this nightmare: I am in Boston. My mind flashes from the past to the future very fast. I usually have a glimpse of me in the courtroom and them putting Daniel in cuffs. Him telling me he loves me. That one of us won’t make it out of this alive. Then I can see the roof of my apartment. Daniel is looking in on me and I’m asleep. I can see him and I know I am sleeping but I can’t move. He comes inside. He is older. He is angry. He is on top of me. I am trying to scream, but nothing will come out. He is choking me. I am dying and I can’t fight back. He is choking me and saying he loves me. Usually here I wake up crying or screaming. It takes me a few moments to get oriented and realize it was just a dream.
It’s important to know that many survivors will go to the same lengths after revealing abuse as before to look and feel like they have survived the trauma and are doing well. These survivors, like Kayla, are skeptical that others will fully understand what they have been through, and their inclination is to avoid and deny the ongoing impact of the abusive relationship on their lives. Kayla desperately did not want what had happened with Daniel to plague her going forward. As we explain later when we discuss complex PTSD, her symptoms functioned to help her avoid fully facing and accepting the impact of her past reality. This tension between wanting others to understand their ongoing distress and wanting the past to “just be over” makes it challenging for the adults in the child’s life to know how and when to respond to symptoms that they observe. Triggered trauma memories and flashbacks are common for abuse victims, but often those closest to the victim have no idea what she is experiencing, as Kayla describes:
Anything can become a trigger. One time I went into a panic attack because someone on the team was wearing the same cologne that Daniel used to wear. I remember the scent hitting my nose and then it was as if there was a flood in my mind. Daniel’s face, happy, screaming, smiling, lustful. I remember I broke out in a sweat and wondered if everyone could tell I was crazy. I remember the rest of that day all I could do was focus on not losing it. On just surviving and being normal until I could get home that night and cry in the shower.
Sometimes at practice I would hear his voice. I would hear him yelling at me. Telling me I was never going to make it without him. I hear him saying I can do better. That I’m not trying hard enough. I can see his face and feel his emotions.
Right before I was admitted to McLean I had a serious episode where I thought I was still in Ohio. I called Brian Daniel and kept laughing and joking with him. I don’t remember any of the episode, except when I came to I was out sitting on the sidewalk in front of the judo house. Brian was terrified and called my mom. The next day she flew out and admitted me to McLean.
COULD YOUR CHILD HAVE PTSD?
Again, hidden symptoms are hard to treat. But does your child need to qualify for a psychiatric diagnosis to get the treatment she needs? This is a complicated issue. In general, the reason for standardized criteria by which psychiatrists, psychologists, and mental health clinicians can render a particular diagnosis is to ensure that the person receives the treatment that research has shown to be most effective for that disorder. But what happens if an individual has many of the symptoms of PTSD, a common consequence of child sexual abuse, but not all of the criteria required by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders? At this point important decisions must be made about whether to take a “wait and see” approach (perhaps the symptoms will disappear or they’ll increase to the point of fulfilling the formal diagnostic criteria) or treat the symptoms now to reduce the harm to the patient.
A significant proportion of youth subjected to sexual abuse will in fact develop symptoms of PTSD, which can significantly interfere with the child’s emotional, mental, and behavioral stability. So of course if your child displayed them you would want to be sure they were treated effectively. The problem is that many people who have PTSD symptoms don’t meet the criteria for a formal psychiatric diagnosis—one intrusive symptom related to the trauma, one symptom of avoidance related to the trauma, two symptoms of negative changes in thoughts and mood since the trauma, and two symptoms of hyperarousal related to the trauma. Without meeting all these criteria, a child could not be given the PTSD diagnosis, and some mental health professionals would therefore hesitate to offer targeted PTSD treatment. However, the evidence-based treatments for PTSD almost all begin with skills training for symptom management, and there’s no reason children cannot receive help with symptoms like nightmares, unjustified feelings of guilt, and harmful avoidance, even if they don’t have a formal PTSD diagnosis. While the child is receiving this skills training (see Chapter 6 for details), the clinician can evaluate whether it makes sense to start a second phase of treatment that typically includes exposure to remembered aspects of the trauma (also explained in Chapter 6) and is focused on reconstructing and processing details of the past sexual abuse.
Also be aware that symptoms stemming from sexual abuse trauma typically evolve over a period of time, and sometimes a child who would not qualify for a diagnosis of PTSD during abuse or immediately after it ends will meet the criteria later. According to the American Psychiatric Association, a majority of individuals exposed to a traumatic life event will experience significant short-term distress, and for sexual abuse victims, particularly when their abuse is ongoing, the chances of eventually developing PTSD are quite high—remember here that PTSD symptoms need to persist for more than a month before this diagnosis can be made. We see many youngsters in our clinical practices who believe the world is not a safe place and that they don’t personally deserve a good life. When we investigate, we find that many of these beliefs can be traced back to sexual abuse by a trusted adult. But this effect often takes time to develop. The younger the child is when the abuse happens, the less likely it is that the child will fully understand that the touching that has been going on for some time is inappropriate. For many victims, like Kayla, it only dawns on them gradually. This full realization in adolescence often leads to increasing distress, which fortunately can lead to disclosure but, unfortunately, also to an increase in PTSD symptoms.
Kayla captures this evolution of her awareness about the relationship with Daniel in some of her original journal entries (see Chapters 1 and 2). Becoming fully aware of his betrayal, while also feeling confused and guilty because she still believed she had colluded in the abuse, caused her to continue to have intrusive memories, nightmares, and scary, dangerous dissociative episodes long past the point that others expected that she would “be fine”—and the same can be true for other abused children. Although the disconnected experience of dissociation “helps” the victim block out extremely painful memories, it can also lead to an inability to experience essential emotions and remember key moments. Dissociation can also lead victims into repeated abusive relationships. For Kayla this ongoing deterioration is captured in multiple recollections of the period after her arrival in Boston and before Daniel is sentenced months later:
Over the first weeks in Boston I was a wreck in the dojo, a puddle of tears. Judo felt dirty now, and everyone, I was sure, was staring and whispering about me. Every time I stepped on the mat, Daniel rematerialized—“What are you doing, girl? You know you can’t do this without me!”—leaving me both loathing him and thinking again that I loved him—trembling over everyone’s expectation that I would testify against him and lock him away.
I felt as if I was going crazy. Panic frequently seized my chest and closed around my windpipe. Anything could trigger it: the smell of Daniel’s cologne on a stranger, a song we used to listen to, a screaming coach.
One night I jumped in my car to escape before something terrible happened, afraid even to stop for gas because the people at the station would know my secret, then drove south on the interstate to start a new life until I finally pulled over, even more scared of what I would do without judo.
Another night, in a blizzard, a panic attack sent me crawling out my window onto the garage roof and leaping down to the yard to evade my worried teammates downstairs, then scrambling through the neighborhood and into a nearby nature reserve.
I later learned that Brian, terrified that I had taken an overdose of sleeping pills, bashed down my locked bedroom door, and then, seeing I was gone, he and seven teammates jumped into three cars to pursue me, a police car joining the hunt.
Kayla’s journal from this time emphasizes how complex the emotional aftermath of a disclosure can be. Kayla continued to feel ambivalent about the disclosure and its repercussions for Daniel and to feel attached to him, which led her to seek contact with him after arriving in Boston. No one in her immediate network of friends and family had any idea, and they undoubtedly would have been both shocked and disapproving. Kayla’s running off and being chased by her friends and the police, it turned out, followed Brian’s discovery that she had been secretly talking to Daniel via a burner phone that she had purchased:
Dear God,
Well, a lot has happened. I’m going to come clean about the big stuff.
When Brian was in Italy I talked to him [Daniel]. I called him and he answered. I hung up. I called him again and he answered. This time he knew it was me.
We talked. We talked about everything. I was so lonely and I need him so much. I missed him. Daniel has always been the rock in my life. He always will be.
So he told me to go buy a phone and use fake stuff and cash, so I did. And then I called him the next night. And the night after that. And the next one. We talked for hours just like we used to, and it made me remember the good times.
But this time something was different. I needed him a little less and he needed me a little more. Lord, please forgive me, because I lied. I told him I wouldn’t testify. I don’t want to, but I know they will make me. I told him I still love him.
It’s like when you cut off your leg—but sometimes still think it’s there. I called him tonight and I could tell he was drunk from the smell of his breath over the phone. Please help me need him less.
Love Always,
Kayla
Kayla was noticing that the focus of her life was changing. Her friends and family thought it had already shifted 180 degrees, and they might have been able to help her (or find a professional who could help her) deal with her confusing emotions if they had understood that the shift can take time, especially when the abuse went on for as long as it had. More knowledge about the aftermath of disclosure might have allowed a caring adult to convey to her that ambivalence is understandable; that understanding, in turn, might have relieved her distress and confusion enough to avoid triggering some of her more potentially self-destructive behaviors like climbing out a window in the dark. While the more adults know, the more effective they can be in listening to and supporting a child who has suffered and disclosed sexual victimization, even this awareness does not guarantee that victims, like Kayla, will not require professional help to lessen their distress and the problem behaviors they may be using to cope with that distress. As Kayla’s mother says:
“After your abuse was disclosed, I worried about you more. I was concerned for your psychological well-being because we felt like you had been, in a sense, brainwashed by Daniel. I was worried because you would call home and tell us you weren’t good enough anymore. Also some of your friends in Boston were concerned that you were continuing to talk with Daniel even though you told us you weren’t. After much nagging on my part, you finally broke down and admitted you had the burner phone, and I believe it was then I came back to Boston to get you into treatment.”
Common Short-Term Symptoms to Watch For
As noted earlier, distress needs to be addressed whether or not the individual has been given a PTSD diagnosis. Consider nightmares. Although nightmares about the abuse alone would not qualify a victim for a PTSD diagnosis, it is clear to parents, teachers, and those of When a child has been traumatized, the specific diagnosis is less important than perceiving the level of individual distress and how we can help the child with it. us in the mental health area who work with children on a daily basis that a child with chronic nightmares and disrupted sleep is not a child who can function effectively and feel happy and successful in his daily life. The same is true for a victim who continues to seek contact with her abuser.
As noted earlier, most victims of repeated sexual abuse have some symptoms of an acute stress response and/or PTSD symptoms both during and in the period following the revelation of their abuse. Everyone in their immediate network needs to remain vigilant when a child or teen who has been sexually traumatized is experiencing any of the following symptoms or, more important, evidences specific changes in behavior that cause the victim at least moderate distress. Behavioral changes to be aware of following the initial disclosure period (see the box below), particularly if these persist for longer than 1 month, are:
Many of the short-term responses to trauma are predictable and not necessarily serious, such as temporarily sleeping poorly or having trouble concentrating, and may disappear eventually without formal treatment. But the only way to ensure that they don’t worsen and interfere with the youth’s healing is to monitor these problems. Children who have suffered the horror of repeated sexual abuse, particularly by someone in a position of authority and trust, are less likely to recover quickly, and reclaim their earlier level of functioning, than those who have had other traumatic experiences. This is why ongoing attention is so crucial. Recovery is not achieved when the abuse ends; it is just beginning.
THE TIME FRAME FOR SYMPTOMS OF DISTRESS
When mental health practitioners try to determine whether a child should be diagnosed with PTSD, the time factor is important yet tricky to consider. With sexual abuse, it is not apparent when the trauma actually begins or ends. But having symptoms like those listed above for up to a month is usually viewed as what is called an acute stress response. If the symptoms develop and persist for a longer time, the practitioner will consider a diagnosis of PTSD.
Longer-Term Harms of Child Sexual Abuse
Victims like Kayla are likely to have nightmares, become extremely fearful, and have other behavioral symptoms like those listed previously, and the earlier they receive appropriate treatment for them—with or without a diagnosis of PTSD—the more quickly they can be resolved. Chapter 6 explains what types of treatment can help and how to get an expert evaluation and diagnosis.
Unfortunately, child sexual abuse is also often associated with a range of other difficulties later in life, including low self-esteem, severe anxiety, phobias, eating disorders, self-destructive behaviors, substance use, and a variety of physical disorders. Whether resolving the short-term behavioral symptoms right away can prevent these long-term outcomes from developing is not entirely clear. It appears that the longer the abuse continues, the more severe it is, the closer to the child the perpetrator was, and the more helplessly trapped the child felt during the abuse, the more likely the trauma is to have long-lasting effects. Fortunately, the effective treatments we have today make recovery possible for the great majority of children. But we reiterate that it is so important to notice problematic symptoms early and address them promptly and persistently.
Here are some highlights of recent research on the longer-term effects of child sexual abuse:
Years of doctors’ observations and research studies have shown that childhood sexual abuse has predictable short-term effects and common long-term effects. But it also gradually became clear that severe, sustained abuse caused damage beyond the symptoms of PTSD as defined by the DSM. From this realization emerged the term complex posttraumatic stress disorder (C-PTSD) to describe a constellation of more far-reaching and multifaceted symptoms. This term was first used in the psychiatric literature in 1992 by Judith Herman 12 years after PTSD first became a formal, recognized diagnosis, and although it’s still not recognized as a formal diagnosis in the DSM-5, this syndrome has been well researched as an important entity in carefully conducted clinical research, as supported by Bessel van der Kolk and colleagues in a comprehensive 2009 review of this literature.
Specifically, complex PTSD results from exposure to repeated, severe, and chronic trauma(s) from which it is difficult for the victim to escape—as is frequently true for sexual abuse that occurs in childhood (as opposed to adulthood, where trauma more often involves a single incident with a stranger or is reported sooner to authorities). Its symptoms fall into seven domains identified in a 2005 review by Dr. Alexandra Cook and colleagues at the Justice Resource Institute (based on a 2003 white paper from the National Child Traumatic Stress Network Complex Trauma Task Force):
Although these terms are somewhat abstract, they give you an idea of how far-reaching the effects of sexual abuse can be in the most severe cases. The abused child or teen may have trouble forming or keeping the normal relationships she had before the abuse started. She may have nightmares and insomnia, gaps in memory, or feel disconnected from reality. She might be impulsive or aggressive, emotionally volatile, and have trouble concentrating and learning. Medical problems and illnesses might crop up without any traceable physical cause. Feeling down on themselves, easily ashamed, and negative is common among long-term abuse victims. As dire as this may sound, good treatment is available, and the sooner symptoms are addressed, the more quickly they can be resolved and the child or teen can recover.
NO LONGER ALONE: INCHING TOWARD PROFESSIONAL HELP
Kayla experienced many symptoms of complex PTSD, including behavioral impulsivity involving self-harm, disturbances in body image, and periods of dissociation, both before and after her disclosure. These symptoms came to the attention of Kayla’s coaches in Boston shortly after her arrival. In thinking back about the first weeks that Kayla lived and trained with them in Boston, the Pedros, both father and son, recall how troubled she appeared to be and remember clearly their mounting worry that, without professional help, Kayla would neither be safe nor able compete at the level she aspired to:
“Kayla wanted to quit judo, to disengage from every part of her life,” recalls Jimmy Pedro Junior, who said he remembers receiving a panicked call one night not long after Kayla arrived in Boston after she had climbed up onto a roof and was threatening to jump; another time, Pedro Junior recalls, she ran away and could not be found for quite some time.”
These behaviors scared both Kayla’s coaches and her teammates, and they began talking with her about seeking professional help, a suggestion that Kayla initially rejected. But the Pedros persevered and, refusing to be daunted by Kayla’s protests, moved forward with a plan to make sure she accepted the help she needed, even making this a requirement for continued judo training:
“She was in a bad place when she showed up,” Pedro Junior said of Kayla. “Her whole world was upside down, and I think she wanted to just sort of disappear. But that girl is a fighter. We eventually got her enrolled in high school. My father and I took on the role of pseudo-parents. We got her talking to a therapist who was also one of our judo students, Dr. Blaise Aguirre, who is also world-renowned for his work with abuse victims, and slowly, she started to come around.”
It was fortunate for Kayla that the adults in her life at that point did not grant her more time to struggle alone with her distress. Studies have shown that PTSD can resolve gradually or spontaneously without specialized treatment, but complex PTSD generally does not, especially It often takes a worsening of symptoms, along with the resolve of concerned adults, for child victims to finally accept that they will need expert help to recover fully and thrive. when it includes symptoms of self-harm and suicidal thinking. At that time Kayla was experiencing periods of dissociation, self-harming behaviors, suicidal thinking, and a deep sense of despair and self-loathing—all characteristic of complex PTSD. In fact Kayla’s symptoms had become so severe in the aftermath of her disclosure that, without professional intervention, her condition would likely have deteriorated further.
Luckily for Kayla, the Pedros were principled in all the ways Daniel had been disreputable. They set appropriate boundaries and helped Kayla mend, insisting, together with Kayla’s mother, that she agree to an admission at McLean Hospital so as to receive the top-notch psychiatric care she needed. But it was still no easy task for Kayla to agree to even a brief stay at McLean, as she worried that taking time out for treatment was an admission of weakness and would also derail her training and dreams of becoming an Olympian. Fortunately for Kayla, she and the Pedros already knew and trusted one of us, Dr. Aguirre, a psychiatrist who is the medical director of a program at McLean designed to help young adults like Kayla recover from trauma-related problems.
The long-standing relationship with the Pedros, along with the availability of a specialized treatment option at McLean Hospital just miles from where Kayla lived and trained, made obtaining professional help possible. In fact to this day I (Blaise Aguirre) feel fortunate that my relationship with the Pedros and love for judo made it possible for me to first meet and then help Kayla get the intensive help she needed shortly after arriving in Boston. As I recall,
“In 2007, Olympic judo bronze medalist Jimmy Pedro came to me with a very specific and confidential request, but in order to get to that here is the context.
“I have always loved the sport of judo and as a medical student in South Africa had practiced it regularly. I also believed in its philosophy. The word judo itself means the gentle way, and is in a sense a contradiction: Judo is the art of nonresistance in the face of aggression. The idea is that, when attacked, you take the anger and action of the other to use against him. The idea of gentle yet effective combat resonated with my perspectives on therapy and my appreciation and application of the treatment I use, one known as dialectical behavior therapy or DBT, a therapy that integrates the Eastern acceptance principles of Zen with the Western therapy of behaviorism.
“Some years after I arrived in the United States I read that Jimmy had won an Olympic medal and was teaching at a gym just up the road from me in Wakefield, Massachusetts. I trained with him from 1998 to 2008 before the demands of my psychiatry practice and ageing body got the better of regular attendance. Nevertheless I had grown close to Jimmy and his family. However, it was that day in 2007 that stands out in my mind. ‘We have a kid coming to train with us. She is great, but she was abused by her coach. She is very emotional and has a hard time being on the mat. Her mother is very worried about her and so are we. Can you help?’
“I met Kayla at the gym. She was serious and dedicated. She trained unlike any other judo player. Each movement precise, each with the same accurate technique, repetition after repetition, rarely resting, never talking or goofing off like the rest of us. She acknowledged that she had been struggling with nightmares, flashbacks, difficult intrusive memories, long crying spells, difficulty sleeping, loss of appetite, and despair. She was someone who had PTSD and perhaps an episode of major depression. I understood the concern of Jimmy and Kayla’s mother, and I had the further worry that she might become so despondent and hopeless that she could end up carrying through with her incessant thoughts of self-destructiveness if she did not get professional help.
“With that concern in mind, I referred Kayla to our adolescent residential unit. She needed to rest and get professional help. Because she was so diligent in her learning of judo, I had no doubt that she would similarly learn some of the techniques that we taught our patients to deal with symptoms similar to hers.”
Taking a Break in Pursuit of Recovery
What Kayla and other sexual abuse victims need help in recognizing and accepting is that someone victimized in childhood must, at times, stop his or her daily routine in order to focus fully on treatment and recovery. Without this pause, victims often remain stuck in cycles where their considerable and unresolved distress leads to escalating avoidance, dissociation, and an undue reliance on destructive coping strategies. The decision to seek professional help was extremely grueling for Kayla even with the unified support of her coaches and family, as she continued not only to question whether she needed therapy in the first place but also to feel deeply ashamed and fearful of placing her faith in yet another new group of people.
Looking back, Kayla remembers only too well the arm-twisting from her mother, who flew to Boston at the last minute to ensure that she accepted the residential admission she now so desperately needed. And Kayla also recalls well the anger she felt toward the very same people who were trying to help her, including the last-ditch efforts to reverse her mother’s decision about the admission, a decision Kayla now feels may well have saved her life:
Even though I agreed to be evaluated, I freaked out once I realized what was really happening, sobbing and screaming as my mother turned her back and left me on the ward. “I will go back to judo,” I remember pleading, “I will do anything; please just don’t leave me here.”
And then she was gone and there was nowhere left to run . . . I was once again alone, alone and frightened and exhausted from the battle I had been waging for such a long time.
That night I remember reluctantly talking to my therapist, Jen, and realizing that she was there to just listen and that the other girls on the unit had even worse problems than me.
And I began thinking that maybe, just maybe, this could help.
Understanding the available options and approaches to the treatment of PTSD and complex PTSD is necessary to get the best possible help for victims of abuse, so we strongly encourage you to read the next chapter. But be aware that the initial challenge is often to help the youth (in addition to those around her, including parents) accept that the impact of childhood trauma does not end with the revelation or discovery of the abuse and that professional help can be enormously beneficial. Only with a great deal of external encouragement will many survivors acknowledge their continued suffering and accept a professional referral they may urgently need.
For many victims, the overwhelming loss of the cloak of anonymity, along with the shame and guilt that can soar to the surface of the child’s emotions, often triggers self-injury and drastically lowers self-esteem. The appearance of these symptoms often brings the child’s distress to our attention—and possibly to yours. For Kayla these symptoms were exacerbated by the changes in her living arrangements and relationships postdisclosure. She had struggled with suicidal thinking and extreme emotional distress for years before her revelations about Daniel, but that distress spilled over into heightened impulsivity, self-harm, and an uptick in suicidal thinking after she arrived in Boston. This is an important lesson for the adults in a victim’s world that we cannot state often enough: Disclosure may not be a relief to the child or teen. It may open the floodgates and impose a new normal that is extremely difficult to manage. The next lesson is just as important: Kayla eventually acquiesced to an evaluation at one of the McLean Hospital programs, but only once it became clear that her coaches and mother were not going to back away from her need for professional help.
The obvious next question is: What is the best type of professional help, and how can you find it? What we know to date is the subject of the next chapter.