DEBRA TAYLOR
Although it is common practice to view group or individual therapy as the treatment of choice for CSA [childhood sexual abuse] survivors, emerging data indicate that this may not always be the most appropriate modality.
Christians have the greatest motivations imaginable for grappling with and responding to the ugly reality of sexual abuse. Christian motivation for sexual abuse ministry can be summed up with a single, pregnant phrase: “The gospel.”
I became a trauma therapist through a back door. I had been a marriage and family therapist (MFT) for a few years, and gradually realized I needed to be able to help couples with their sexuality if I was going to be an effective marital therapist, so I began training to become a sex therapist. Once I was certified as a sex therapist, I received many enquiries about my services from women who had been sexually abused in childhood. Predominantly a couples therapist, I sought training on how to help survivors of sexual abuse. I attended workshops taught by experts and rising stars in the trauma therapy field. Throughout the 1980s and early 1990s (the era of beepers that went off at all hours of the night and of the false memory wars, and the era before MFTs were taught much about boundaries or about vicarious traumatization), I worked with many trauma clients.
I had been taught to do therapy from a family systems model and had been trained in couples therapy by an exceptionally gifted couples therapist. Yet I did not question when all of the “experts” were directing me to work individually with trauma victims. They were the experts; I was trying to help my clients stay alive, to heal, and to learn how to live. Who was I to question the experts’ methods?
I realize now that many of the “experts” I was rushing off to learn from, or whose books I was reading, were, like myself, learning as they worked. It took me many years to understand that most therapists in that era had been trained as individual therapists. They did what they were trained to do—they saw their clients individually. Working with couples requires a different strategy and different skills than does working with individuals. Couple therapy is not just doing individual therapy with two people in the room. Even with nontrauma couples, it requires more structure and can escalate very quickly; couple therapy requires more active interventions from the therapist (Doherty, 2002).
Certainly for many trauma survivors, and particularly for complex trauma survivors, life, and therefore therapy, is extremely chaotic. Working in therapy with all that chaos—the chaos of the survivor, the chaos of the hurting/angry spouse, and the fragmented or rupturing marriage—demands a lot of any therapist and any couple. Despite these challenges, the therapist must maintain the therapy office as a safe environment. As Pistorello and Follette (1998) write, “The therapist must guard diligently against repeated emotional victimization of the survivor by the partner in the therapy session. Research has clearly documented the risk of revictimization for CSA [childhood sexual abuse] survivors. . . . It is incumbent on the therapist not to recreate this process in the therapy session” (p. 481). So in part to keep the trauma survivor “safe,” most therapists did, and still do, work with them individually.
During my first two decades of education, training, and attempting to help trauma survivors, I felt a very distinct tension and stress. While I and many of my colleagues were working in our therapy rooms with individual survivors, the spouses (or intimate partners) were hurting, frustrated, angry, and usually pressuring the survivor for more relationship, more affection, and, especially, more sex. The partners wanted to know what was happening in therapy; was anything happening that might improve the survivor’s life and therefore the couple’s romantic relationship? Often, even if I tried to refer the survivor and partner to a couples therapist to work on their relationship while I worked with the survivor on the trauma, they were financially unable to do both.
In the past few years I have stumbled across a few voices in the trauma field saying there is a need to work with the couple in healing trauma; several of these voices have been saying this for more than a decade. For some reason I, and apparently many other helping professionals, missed these voices. This chapter takes a closer look at the rationale for and models of working with couples when one or both partners are trauma survivors.
At least one in four children have experienced physical, emotional, or sexual abuse and/or childhood neglect. These children’s brain development will be affected, and they may have impaired learning abilities, lower language development, and impaired social and emotional skills (Centers for Disease Control and Prevention [CDC], 2016). Exposure to multiple forms of trauma or exposure to repeated instances of trauma over a period of time, usually involving interpersonal betrayal, is called “complex trauma” (Cloitre, Courtois, Carapezza, Stolbach, & Green, 2011). Studies of adults indicate that over 20% of women and 4% of men have been sexually assaulted after the age of 18 (Elliot, Mok, & Briere, 2004). The most common example of complex trauma is repeated childhood sexual abuse.
The prevalence of reported sexual abuse varies widely depending on the population surveyed and the definitions, measures, and research methods used. An examination of multiple studies shows that 8%–30% of women and 2%–16% of men across all socioeconomic and ethnic groups have experienced sexual abuse involving inappropriate touch prior to age 17 (Bebbington et al., 2011). Prevalence rates are most likely underestimated due to underreporting of sexual assault and the myth that continues to pervade the culture that boys are rarely sexually abused and men are rarely raped. There is evidence that sexual-abuse rates have risen in American adolescent and young adult women. The limited data available with respect to Christians and sexual abuse suggest that rates are about the same as those of the general population (Tracy, 2011).
“It is arguably one of the great miracles of our species that in the face of violation and terror, those who have been abused continue to seek out and long for connection with others.”
H. B. MacIntosh and S. Johnson, 2008
A trauma survivor has to react and adapt to abnormal, disturbing, and damaging experiences. These reactions and adaptations evolve into usual functioning for the survivor, so that he or she lives in survival mode physically, mentally, and emotionally even after the danger has passed (Courtois & Ford, 2013). Over time, these survival defenses can cause psychological, relational, and physical problems. Chapters ten and eleven discuss in greater detail the impact of complex trauma on survivors; how these effects impact the relationship are highlighted in this section.
Dysregulation of affect. One of the most profound effects of trauma is the dysregulation of affect. Many trauma survivors become imprisoned by their own emotions, flipping between being flooded with intense emotions and physiological distress and then being unable to feel or express any emotion. The survivor’s brain is not able to modulate emotional arousal; he or she is not able to tolerate and contain intense emotion. Yet affect regulation is crucial for healthy, long-lasting relationships.
The “hijacked” brain. Trauma tends to cause the brain to see danger and threat everywhere. The survivor frequently misreads circumstances, facial expressions, and others’ intentions, causing blowups or shutdowns in relationships, keeping the trauma survivor hypervigilant, verging on fight-flight-freeze most of the time. This makes it much more difficult to control impulses or emotions (van der Kolk, 2014). When trauma remains unprocessed, the brain gets “hijacked.” The brainstem overrides inhibition, so the survivor cannot stop inappropriate reactions or refocus attention. Shifts in blood flow in the brain decrease language ability or memory and increase feelings of sorrow, sadness, and anger. The hijacked brain makes it very difficult for survivors to calm themselves down (Cohn, 2011). The impact of trauma on the brain is covered in depth in chapter three. To work with couples well, the therapist must keep in mind the tendency for trauma survivors to get hijacked.
Impact on adult attachment. All forms of abuse or neglect affect development and can drastically alter how a person forms and maintains attachments in childhood and throughout adulthood (Hecker, 2007). Sexual trauma has consistently been reported to have a severe impact on a person’s ability to participate in a fulfilling couple relationship (Rellini, 2014; Zala, 2012). Many survivors of child sexual abuse report relationship problems, believe their relationships are less healthy than others’ relationships, and feel unable to depend on their partners (MacIntosh & Johnson, 2008). Survivors of childhood sexual trauma experience higher rates of marital separation and divorce (Meston, Lorenz, & Stephenson, 2013; Watson & Halford, 2010) and are significantly more likely to suffer maltreatment from their partners (MacIntosh & Johnson, 2008). Couples in which a partner is diagnosed with posttraumatic stress disorder (PTSD), a common result of sexual trauma, have been shown to be three to six times more likely to divorce than those without PTSD (Monson & Fredman, 2012).
Attachment theory helps to explain why early experiences influence romantic relationships in adulthood. As Bowlby (1988), the originator of attachment theory, writes, “All of us, from the cradle to the grave, are happiest when life is organised as a series of excursions, long or short, from the secure base provided for us by our attachment figure(s)” (p. 62). Couples who are securely attached exhibit greater commitment and levels of trust as well as satisfaction within their relationship (MacIntosh & Johnson, 2008).
When early attachment relationships are disrupted by trauma, there is usually disruption in childhood attachment style that persists into adulthood. Problems within a couple’s relationship are frequently about the (in)security of the bond between the partners and each partner’s need for the relationship to be a safe haven and a secure base (Johnson, 2003).
Fear of abandonment. Trust issues are prevalent for survivors of sexual abuse (Courtois & Ford, 2013). The survivor may anticipate abandonment and be intensely sensitive to any distancing on the part of the spouse. The survivor may withdraw from the partner or create conditions that would cause the partner to leave. The survivor may be irritable and precipitate fights or engage in tension-reducing behaviors such as drug or alcohol use or disordered eating that may cause the partner to feel angry or alone. The survivor may be secretive about his or her previous abuse, afraid that the partner will leave if he or she knows “everything” (Courtois & Ford, 2013; Hecker, 2007).
Impact on other areas. The trauma survivor may be fearful of overburdening the partner or may dread that the partner will share the information with other people. The survivor may also believe that the partner will use the knowledge against the survivor, or that the partner will not listen or be able to empathize with the survivor. Trauma may also affect the survivor’s spirituality, restricting the survivor’s and the couple’s ability to use shared faith as a resource for healing (Hecker, 2007).
“I find the trauma literature about sexual recovery to be sorely impoverished. . . . My reading has shown partners of survivors presented as cardboard cutouts, called upon to be patient, supportive and self-sustaining through the difficult journey of trauma recovery. Certainly not my experience of them in the room.”
R. Cohn, 2011
Neglect is the failure to provide for a child’s basic needs—physical, emotional, medical, or educational (CDC, 2016). Cohn (2011) found in her 30 years of working with trauma survivors that it is common for the partner of the survivor to be a survivor of childhood neglect. With the focus on the trauma survivor, the child of neglect continues to be invisible—to be neglected. This partnering of trauma survivor with neglect survivor essentially locks the couple into a negative pattern of reenacting their childhood torment and triggering their attachment wounds.
Trust is not just a problem for survivors of trauma; trust is also an issue for most children of neglect. While obvious trauma is about what happened, the problem of neglect is about what did not happen (Cohn, 2011). People neglected as children had absent or dismissive caregivers. For these infants and children, it was pointless to cry or protest (Bowlby, 1988). They learned early that the way to survive was to become self-sufficient, to not need. Some of these children, never nurtured or mirrored by their parents, did not become aware of their feelings or needs and may not know what they want or like, even as adults. They are usually experts on their trauma partner’s story, keenly focused on their partner’s problems, needs, and healing (Cohn, 2011). They may not really have a story of their own. Often survivors of neglect look successful and are autonomous, and they may be high achievers. Interpersonally, however, they frequently feel powerless and mistrustful. For both trauma survivor and neglect survivor, the path to resolving issues of trust must be in the context of a relationship, ideally their marital relationship (Cohn, 2011; Feinauer, 1989).
It is common for survivors of childhood sexual trauma to report sexual difficulties: lack of sexual pleasure, sexual dysfunctions, or dissatisfaction with their sexual relationship (Barnes, 1995; Draucker & Martsolf, 2006). Some survivors are more likely to engage in risky or dangerous sexual behaviors or sexual compulsivity; others are sexually avoidant (Bouchard, Godbout, & Sabourin, 2009; Schnurr et al., 2009). Both women and men who have been sexually assaulted or raped as adults frequently develop sexual dysfunctions (de Silva, 2001). Laumann, Paik, & Rosen (1999) found that both male and female victims of unwanted sexual contact experienced sexual problems much more often than those without unwanted sexual contact. Women sexual abuse survivors describe their bodies more negatively than nonabused women. They also do not attribute positive meaning to sexual expression as frequently as women who were not abused (Colangelo & Keefe-Cooperman, 2012).
It is often mystifying and frustrating for many survivors and partners that sexual intimacy did not appear to be a problem in the early stages of their relationship. This seemingly easy sexual functioning is at least partly due to a “biochemical cocktail” that human brains and bodies produce in the early stages of a relationship. Approximately 3–18 months into the relationship, the partners’ usual sexual baseline reemerges, leaving many couples, not just trauma couples, wondering what happened (Cohn, 2011). Often survivors function sexually in the early stages of romantic relationships but begin to struggle or completely break down sexually after their relationship moves into being “family,” either after marriage or the birth of children (Buttenheim & Levendosky, 1994; W. Maltz, personal communication, July 23, 2015).
If professionals insist that trauma survivors work independently of their intimate partner until the trauma processing has been completed, what is the couple to do with their relationship distress? Is it possible to build couple therapy into the treatment model? Could couple therapy be the treatment model?
Importance of supportive relationships. Helping CSA survivors and their partners attain or maintain a positive marital relationship has been shown to decrease levels of depression, a very common symptom in survivors (Baucom, Whisman, & Paprocki, 2012). Research has demonstrated that survivors of sexual abuse who are able to establish healthy relationships have fewer trauma symptoms. In several studies, resiliency and overcoming abuse symptoms were associated with the survivor having supportive relationships, being married, developing self-regard, and being religious or spiritual (Feinauer, Callahan, & Hilton, 1996). The results of these studies were so compelling that these researchers concluded, “Therapists must consider conjoint therapy with abused women and their partners as part of the therapeutic regimen for survivors of sexual abuse” (p. 105).
Survivors of sexual trauma arrive at therapy in a variety of ways and with divergent presenting problems. They may present individually, directly asking for help to recover from their trauma. Alternatively, their presenting issues might be depression, anxiety, self-injury, substance abuse, migraines, or other physical ailments. Survivors frequently come to therapy because of relationship problems or sexual problems, and they are unaware that these problems may be linked to their childhood abuse or neglect (Cohn, 2011; Maltz, 2002). Many couples struggle because traumatized individuals have difficulty getting close or staying close to a partner since they careen between hyperarousal, anger, numbing, and dissociation (Greenman & Johnson, 2012).
As mentioned, most trauma therapy focuses on the individual survivor. However, disempowerment and disconnection from others are the two core experiences of psychological trauma (Herman, 1992). To recover, then, the survivor must be empowered and new connections with trustworthy people must be made. Herman (1992) states, “Recovery can take place only within the context of relationships; it cannot occur in isolation” (p. 134). Most of the trauma literature assumes that this recovery relationship applies exclusively to the therapeutic relationship and the client’s experience of safety with the therapist (Briere & Scott, 2015; Zala, 2012).
Somehow healing and recovery from trauma and its effects have become the domain of mental health professionals. Yet in the middle of the night when the trauma survivor is experiencing a traumatic nightmare or flashback, it will be the intimate partner who is present, not the therapist. If the partner is told to wait on the sidelines while the trauma survivor works with the therapist on healing, what is the couple supposed to do when those inevitable trauma reactions happen outside therapy? Perhaps therapists have overlooked “the brilliance of ordinary people in healing themselves and the people they love” (Johnson, 2002, p. 7).
Needs of the spouse/romantic partner. Sexual traumatization affects not only the victim but also the survivor’s spouse or intimate partner and often is expressed in ongoing conflict between partners (Barnes, 1995). Partners of survivors of sexual trauma report feeling frustrated, isolated, angry, dissatisfied, and unable to communicate well with the survivor (MacIntosh & Johnson, 2008). If and when the trauma survivor seeks help, therapy is usually conducted individually, and partners report feeling left out of the process. They also report that often both the survivor and the therapist view them like perpetrators, or at least potential perpetrators, from whom the survivor needs to be protected. Partners also feel they are forced to wait until therapy concludes—sometimes years—to have a relationship with their spouse (MacIntosh & Johnson, 2008). How can therapists best help couples who are facing the relational and sexual impacts of trauma? Should partners be expected to put their relationship and sexual needs on hold while the survivor works individually in therapy?
Maltz (2012) asserts that the survivor’s partner is a “secondary victim” of the sexual abuse. As early as 1996, Reid, Wampler, and Taylor conducted in-depth interviews with the husbands of women who had been sexually abused. These survivors’ partners emphasized a need for information regarding the impact of childhood sexual abuse on marriage and what to expect while the survivor is in therapy, and they wanted couple therapy as part of the healing process. Spouses of trauma survivors felt strongly that they had been kept in the dark, that the therapist did not want them in the sessions, and expressed feelings of alienation from the therapy process. The authors recommended that therapists integrate conjoint couple therapy as an adjunct to the survivor’s individual or group therapy (Reid, Wampler, & Taylor, 1996).
Stigmatization of the victim. To date, most trauma therapies advocate explicitly or implicitly that the partner wait while the survivor works individually on healing the trauma before addressing relationship problems. When trauma treatment does include the partner in some way, usually the goal is to educate the partner so that the partner can be more helpful and supportive to the survivor (Hecker, 2011; Miehls & Basham, 2004). This reinforces the assumption—by the survivor, the spouse, and the therapist—that the survivor’s history of abuse is the cause of all of the couple’s relational difficulties and the partner is the long-suffering, deprived saint. Pistorello and Follette (1998) caution that “this process of ‘benevolent blame’ tends to promote the stigmatization of the survivor and may lead the couple to avoid current difficulties by focusing exclusively on historical events” (p. 480).
Specific models for working with couples in which one is a survivor are described in the following section. However, whichever overall model is used, it is important first to address issues that interfere with the formation or maintenance of couple attachment and the couple’s sexual relationship as well as spiritual issues, which are especially important for Christian couples.
Relational issues and attachment. Attachment theorists contend that an essential component of posttraumatic healing is the creation of loving, supportive bonds between romantic partners (Greenman & Johnson, 2012). Attachment theorists and therapists also assert that the three behavioral systems of attachment, caregiving, and sexuality must be integrated to develop a secure, healthy adult pair bond (Butzer & Campbell, 2008; Johnson, 2002). By viewing the couple through an attachment frame and helping a couple to see each other through the lens of attachment, the therapist and the partners can understand the environment in which each partner learned to relate and can value their attempts to adapt (Johnson, 2009).
Sidestepping the relational conflicts or sexual concerns between the survivor and partner, while understandable in the midst of the survivor’s trauma history and symptoms, may in the long run lead to further relationship dissatisfaction and even dissolution. Without intervention, many survivors who establish a relationship with a partner who has a secure attachment style cannot believe that they deserve a healthy relationship and end up leaving or otherwise sabotaging the relationship (Courtois & Ford, 2013). Focusing on the couple and their concerns, even sexual concerns, early in trauma therapy versus waiting until the later stages of therapy may prove to be a better strategy.
Sexual healing for survivor couples. When a couple specifically comes to therapy to work together on sexual healing, emphasizing safety, deescalating the negative cycle between the couple, and establishing a secure base are primary goals (Courtois & Ford, 2013). Shifting to viewing the sexual problem as serving a function for the survivor and for the couple and exploring its function is one key to navigating this stage (Maltz, 2012). The survivor is encouraged, along with the partner, to exercise choice in the treatment goals, and the therapist uses a nonauthoritarian, collaborative style. Sexual healing should be empowering for both partners. Examining and changing sexual attitudes from abusive (e.g., “sex is an obligation”) to positive (e.g., “sex is a choice”) is a major aspect of sexual healing with survivors (Maltz, 2012).
In her classic book The Sexual Healing Journey, Maltz (2012) has designed specific exercises that survivors and their partners can practice, both individually and together, to relearn touch. These exercises are useful to help survivors stay present in the moment, relax, and communicate about their sensations, reactions, and emotions about touch. These are not typical sex therapy exercises; they are simpler and more playful and are usually done fully clothed. Maltz’s exercises involve learning, sometimes for the first time for men or women who were abused as children, what gradual growth in childlike and affectionate touch is like (Maltz, 2002, 2012). Over time and with repetition of the relearning touch exercises, the couple may choose to move toward more sensual and sexual exercises such as those described by Rosenau (2002).
Spiritual issues. Depending on the individual, the partner, and their joint healing journey, working on trauma can have positive or negative effects on faith. This is an important area for the therapist to directly inquire about during assessment. Survivors may experience a greater sense of closeness to God or greater dependence on God, or they may question God and distance themselves from God or the church (National Center for PTSD, 2016b; Tracy, 2005). The spouse may feel dismay, fear, abandonment, or anger as the survivor wrestles with faith issues or seems to reject God. Modeling acceptance and openness, the therapist can maintain rapport with each partner and work collaboratively with the couple in exploring therapeutic goals that include their spiritual life individually and as a couple.
Being a part of a healthy church can have a positive impact on common trauma symptoms such as isolation, guilt, anger, and lack of meaning. However, rigid or judgmental attitudes from church leadership, Christian friendships, or the spouse can add to the survivor’s sense of isolation, shame, anger, anxiety, and depression. The early phase of treatment in each of the models of couple therapy explained below focuses on stabilization, including helping the couple to develop acceptance for each other and positive communication with each other. Communication skills and education regarding trauma symptoms, the brain, emotional regulation, and attachment can be integrated into the survivor’s and the partner’s spiritual journey. Chapters one and four discussed trauma and faith in more depth.
“Sal Minuchin suggested that rather than relying on magical gurus to create change, we have to make family members healers of each other.”
S. M. Johnson and A. K. Wittenborn, 2012
It is difficult to design one therapy protocol for all survivors of CSA, or to predict how long healing will take, because of the differences in abuse survivors’ histories, losses, coping skills, and severity of pathology. In individual therapy, some survivors work through the three stages of trauma therapy in less than a year, some will need several years, and others decades (Courtois, 2004; Herman, 1992). What can couples and therapists expect when working on healing trauma through couple therapy?
Several resources are available to therapists to guide them as they work with couples on relational and sexual healing from the effects of sexual trauma (Basham & Miehls, 2004; Cohn, 2011; Greenman & Johnson, 2012; Maltz, 2012). No studies have definitively shown the superiority of couple therapy over individual therapy for CSA recovery or other trauma recovery. However, the findings from recent research studies reinforce the notion that “directly intervening with people’s most central interpersonal relationships might result in important changes not only in the patient with psychopathology, but also in their partner and in their ongoing relationship” (Baucom, Whisman, & Paprocki, 2012, pp. 267-68). For example, studies with depressed clients comparing conjoint therapy to individual therapy indicate that both produce improvement in depression, but couple therapy results in better communication between the couple, improved relationship quality, and lower negativity between partners (Gilliam & Cottone, 2005).
There is a growing literature to encourage the use of couple therapy for the treatment of trauma, either as the primary treatment modality or as a concurrent adjunct to individual therapy. Some of these resources are manualized treatments and are intended to be followed as written. Others pull together several theories or modalities and give guidance on how to use these different views and tools in working with trauma couples. Others encourage the therapist to integrate couple therapy into the therapist’s usual approach for working with trauma. Trauma therapy for couples has been and is currently being studied using emotionally focused therapy (Johnson, 2004), structural family therapy integrated with eye movement desensitization and reprocessing (Koedam, 2007), cognitive-behavioral conjoint therapy (Monson & Fredman, 2012), object-relations couples therapy (Basham & Miehls, 2004), and syntheses using aspects of trauma theory with parts of Imago Relationship Therapy and Gottman Method Couples Therapy (Cohn, 2011).
A summary of four well-formulated couple therapies for trauma follows. I strongly encourage you to determine which of these or others in the reference section appeals to you and fits with your previous training. Through further training and supervision in a treatment approach, become better equipped to help couples in which one or both partners have experienced trauma and neglect.
Cognitive-behavioral conjoint therapy for PTSD. CBCT for PTSD was designed to integrate evidence-based couple therapy interventions and individual cognitive-behavioral PTSD treatment into a protocol that treats PTSD and enhances intimate relational functioning (Monson & Fredman, 2015). There is a very strong association between lack of social support and PTSD. CBCT for PTSD has been demonstrated to improve PTSD symptoms and the mental health of the partner and to increase satisfaction within the relationship, a three-for-one benefit for this therapy. It has also demonstrated efficacy in treating depression, panic and anxiety, substance use, and anger (Monson & Fredman, 2012).
CBCT for PTSD is a three-phase, sequentially delivered, 15-session, manualized treatment. It is a standalone treatment, a primary treatment for PTSD, and not an adjunct to individual therapy. All sessions are conducted conjointly for 75 minutes per session. Prior to beginning the treatment, the couple participates in three assessment sessions: one conjoint session and one individual session for each partner. In these sessions the structure and requirements of the program are discussed explicitly with the partners, their motivation for full participation in the program is assessed, and informed consent is acquired.
The first session presents the rationale for treatment and important information about the effects of PTSD and how symptoms of reexperiencing, avoidance, emotional numbing, and hyperarousal affect relationships. In future sessions, education and practice are designed to increase relationship satisfaction, undermine the avoidance that maintains both the PTSD and the relationship problems, and make meaning of the traumatic events that caused the PTSD. Specific skills that the couple develops over the 15 sessions include communicating well, identifying and sharing feelings, observing PTSD-related cognitions, making plans to “shrink” PTSD in the relationship, and working as a united team to explore and change trauma-related thoughts (Monson & Fredman, 2012). These skills are conceptualized in and remembered through the acronym “RESUME Living” (Monson & Fredman, 2015).
In this model, both in-session and between-session skills practice are essential (Monson & Fredman, 2012). In each therapy session the therapist and couple review the at-home practice, new skills are taught, and the couple practices the new skills in session. At the close of each session the next out-of-session practice is assigned.
There are at least three reasons to consider using CBCT in the treatment of couples in which one partner is a trauma survivor. First, since it is a manualized treatment, the therapist who has not been trained in a couples approach to working with trauma is able to follow a detailed guide to develop competence and grow in confidence in providing conjoint trauma therapy. Second, CBCT for PTSD has been researched and shown effective with couples similar to the types of trauma couples everyday clinicians see—for example, couples with substance abuse problems, couples in which both partners have experienced trauma or neglect, couples in which one of the partners has a major mental health diagnosis that is being treated and is stable, couples with a partner with mild cognitive impairment, and couples with a partner with non-imminent suicidality (Monson & Fredman, 2015; Monson et al., 2012). Third, many individuals and couples express reticence about participating in individual therapy yet report that they are willing to participate in couple counseling or family therapy (Monson & Fredman, 2012). Military couples in particular have reported that they are willing to participate in this type of therapy for the sake of their family but would be unwilling to attend individual therapy.
Emotionally focused couple therapy. Relationship distress often undermines healing from trauma. Survivors of complex trauma associate closeness and dependency with fear and suffering. Couple therapy is an opportunity to create a corrective emotional experience of safe connection, which can soothe and heal wounds caused by past trauma (Johnson, 2004).
The goal of emotionally focused therapy (EFT) is for the couple to create (or recreate) a safe haven of secure attachment. Securely attached individuals can regulate their emotions when facing stress, openly ask for their needs for comfort and reassurance to be met, and take in and use comfort to calm themselves. Therefore, when the couple becomes more securely attached through working in therapy, they will be able to ameliorate one of the more serious consequences of trauma, that is, affect dysregulation and the inability to self-soothe (Johnson, 2004).
Traditionally, EFT is conducted in three stages that include nine steps. In EFT trauma treatment, these stages are adapted, with Stage 1 encompassing stabilization. This includes identifying relationship cycles, patterns, and feelings; framing the negative patterns as the problem; and deescalating the negative cycles. In Stage 2 the goals are building individual and relationship capacities by retructuring the relationship into a more secure bond, acceptance of the partner and acceptance by the partner, eliciting empathic responsiveness, and asking for needs to be met. Stage 3 encompasses consolidation and integration. In Stage 3 the partners actively problem-solve and assimilate changes from therapy into their everyday lives (Johnson, 2004).
In research settings EFT is completed in 10–12 sessions. When working with trauma survivors, the pace must be slower and may take 30 sessions or more (Greenman & Johnson, 2012; MacIntosh, 2013). Unlike traditional EFT, which does not include psychoeducation, education about trauma must be included. Another difference between working in traditional EFT and EFT with trauma survivors is the need to liaise with individual therapists who may be working with the partners. Also, it is more important to assess and address possible violence and self-harming behaviors, requiring setting up safety nets or agreed-on coping behaviors (Johnson, 2002).
In working with survivors, the therapist must be even more aware than in traditional EFT of the alliance between the therapist and each partner. Rifts in the therapeutic alliance must be closely monitored and quickly mended so that the therapy session is a safe haven for each partner. Couples-specific goals, such as a survivor’s need to be in control of sexuality or a spouse’s disappointment with the sexual relationship, must be acknowledged and woven into therapy goals.
A preliminary research study of EFT with extremely distressed couples in which at least one member was a child sexual abuse survivor, indicates that the greatest area of challenge for CSA survivors is affect regulation. Common characteristics of survivors, such as hypervigilance, inability to trust, shame, and anger, complicate and slow down EFT treatment (MacIntosh & Johnson, 2008). This study also confirmed and highlighted several survivor themes affecting couple therapy: (a) feelings are overwhelming and dangerous; (b) I will lose control if I allow myself to feel; (c) I can’t stay present in emotionally difficult situations (dissociation); (d) limited range of emotions, emotional reactivity, and being easily flooded; (e) I am wounded and unlovable; (f) I am not safe; I must be (hyper)vigilant regarding my partner because she or he will fail me; (g) sex triggers me, so I must control my and our sexuality (MacIntosh & Johnson, 2008). Studies with more couples need to be done to confirm these findings; however, the themes discovered in this qualitative study are substantiated throughout the trauma literature.
Object relations couple therapy. Basham and Miehls set out to produce an “effective culturally responsive couple therapy practice model” (2004, p. 10) for single-trauma or dual-trauma couples. They emphasize that their model is not an integration of various models but a synthesis using social theory, family theory, trauma theory, object relations theory, and attachment theory as different lenses, which are used to a greater or lesser degree according to what most benefits the unique couple with whom the therapist is working.
This couples therapy model begins with assessment and then progresses flexibly through three phases. The phases are related to classic individual trauma therapy. Phase 1 is safety, stabilization, and the establishment of an environment conducive to change. Phase 2 consists of in-depth reflection on the trauma narrative(s). Phase 3 involves the consolidation of new perspectives, attitudes, and behaviors related to the relationship.
Basham and Miehls (2004) describe couple therapy as “a challenging journey” and emphasize that a thorough biopsychosocial assessment is the compass that guides the therapy. The assessment also anchors and focuses the work. The initial assessment first determines whether the couple has food and shelter and is free from violence. Couple therapy is contraindicated in this model if physical violence between the couple is a presenting problem.
Further assessment includes “institutional factors” such as the clinician’s biases and responses, the political climate, disabilities, faith-based community, extended family, ethnicity, and sexual orientation—as these all have roles in making the aftereffects of trauma either better or worse. “Interactional factors” such as intimacy, power, touch and sexuality, boundaries, communication, rituals, and the application and internalization of the victim-victimizer-bystander paradigm (see explanation below) all need to be assessed. Intrapersonal factors such as areas of resilience, PTSD symptomatology, attachment style, and object relations complete the biopsychosocial assessment (Basham & Miehls, 2004).
Phase 1 focuses a great deal on self-care, including education about PTSD and complex trauma, strategies for stress reduction, regulating affect, and self-soothing. Often during this phase the therapist needs to collaborate with other health professionals, probation officers, or the Department of Social Services (Basham & Miehls, 2004). Referrals for psychiatric consultation, medical consultation, or adjunctive activities such as yoga, meditation, hypnosis, massage, acupuncture, or neurofeedback may be given. The victim-victimizer-bystander paradigm, a key concept in this model, is introduced to the couple. Basham and Miehls posit that not only have trauma victims experienced victimization by a perpetrator, and a bystander either refused to help or dramatically rescued them, but also that survivors have internalized this template and it informs their worldview. Phase 1 encompasses a range of “psychoeducational, cognitive-behavioral, body-mind, spiritual, and ego-supportive interventions that promote adaptation and coping” (p. 136).
As is now true in individual trauma therapy, effective Phase 1 work may be the completion of therapy for many couples (Basham & Miehls, 2004; Courtois & Ford, 2013). However, if the therapist and couple agree to proceed beyond the stabilization phase, Phase 2 involves reflecting on the survivor’s trauma experience(s) without full emotional reexperiencing. The goal of Phase 2 is the integration of affect, cognition, and memory. Another goal during this phase is empathic attunement as the survivor and partner share their trauma experiences. These actions are for the purpose of “restorying the narratives with a new focus on resiliency and adaptation” (Basham & Miehls, 2004, p. 136).
Phase 3 involves consolidating new perspectives, attitudes, and behaviors. This includes family of origin work, enhancing the couple’s sexual relationship, and strengthening other family and community relationships. Further work at owning each of the victim-victimizer-bystander roles also happens during this phase. As in traditional individual therapy for trauma recovery, expansion and growth themes are explored in Phase 3. For example, some couples may work on their parenting roles; others may find political or social advocacy regarding trauma to be important for their growth (Basham & Miehls, 2004).
Coming Home to Passion. Cohn’s (2011) therapy is a synthesis of trauma and neglect therapy, Imago Relationship Therapy, communication skills training, sex therapy, attachment theory, and brain neurobiology. Coming Home to Passion is written as much for clients as for therapists and could be used as bibliotherapy with the couple or by the therapist as an outline for working through the couple’s communication, attachment, and sexual problems.
Cohn’s approach begins with an assessment of each partner’s attachment style, core wound, and primary defense strategy, and how these interact. The therapist assesses the couple’s “toolbox”: how they listen, empathize, and speak to each other. Are they able to access and express emotion? Are they able to repair misunderstandings and misattunements? When and how do they each get triggered?
When the assessment is complete, Cohn begins by outlining attachment theory and its application to relationships. She introduces multiple communication concepts and teaches skills in self-awareness, talking, listening, and repairing misunderstandings.
One of Cohn’s biggest contributions to advancing the trauma literature and to working with survivor couples is her belief, discussed earlier, that frequently one partner is a trauma survivor and the other is a survivor of childhood neglect. From my own thirty years of working with trauma, it is enlightening to look back and see Cohn’s hypothesis played out in most of the trauma couples with whom I have worked. She helps the neglect survivor to identify and own their losses and to understand how childhood neglect has shaped them. Cohn holds adamantly to the belief that both partners contribute equally to their relational difficulties and urges the couple to recognize that their relationship problems are not the fault of the trauma survivor, the survivor’s symptoms, or their trauma history (Cohn, 2011).
Cohn also educates the couple regarding how trauma or neglect shapes the brain. She summarizes how trauma shuts down the thinking, adult brain and the speech centers and how it activates the emotions and fight or flight response. Trauma primes the brain and body to look for danger constantly. When the brain sees the environment as dangerous or a trauma memory gets activated, the brain reexperiences the trauma as if it were happening right now (van der Kolk, 2014). Cohn is realistic about the damage trauma and neglect do to the brain, but she also expresses encouragement that the brain can change. Healing is possible.
The repetitive triggering and reactivity in survivor couples is retraumatizing to both partners; it primes the brain for more fear, more stress hormones, and more depression. The cycle can lead to despair and hopelessness. However, the cycle can be stopped. To keep the cycle going both partners must participate, but either partner can use skills acquired through therapy to stop the triggering and reactivity and interrupt the cycle.
Most survivors of sexual trauma and survivors of neglect are not taught basic sexual information. Cohn provides this information and explains how trauma and neglect typically affect sexuality. Often the impasse over their sexuality has resulted in explosive or seething anger, bitterness, withdrawal, or despair. The attachment and trauma information as well as the communication and repair skills they have learned help the couple to experience empathy and warmth with each other. Then Cohn introduces “Practices,” slow, gradual exercises beginning with breathing, learning to be in your own body, and being present with each other. Other practices involve remembering positive sexual times, if any, in the couple’s relationship, casting a vision for the their future relationship, discussing initiation rituals, and eventually exploring each other’s bodies. These exercises involve reflecting, writing, and then sharing their thoughts and feelings, using the communication tools the couple has learned in therapy.
“Jesus’ earthly ministry was characterized by focused outreach to the marginalized, oppressed, and abused.”
S. R. Tracy, 2011
It is my personal conviction that the field of trauma therapy needs to shift toward using couple therapy to treat couples in which one or both partners are sexual abuse survivors and that this shift is beginning to happen. Even when the survivor seeks therapy individually, both therapist and client should consider inviting the partner to join in the therapy process. Integrating the partner into the therapy could give the survivor an ally in the often difficult and lengthy process of recovery from complex trauma. Conjoint therapy can enable the partner to participate in healing rather than be left out (MacIntosh & Johnson, 2008). Johnson (2002) asserts that “couple interventions can make a crucial, and to date almost unrecognized, contribution in the treatment of traumatic stress” (p. 9).
More research on couple therapy for trauma and neglect survivors is necessary. Even more than research, though, more therapists are needed who are trained and skilled in some method of working with couples affected by trauma. Also, more nontrauma couples therapists must become trauma-informed. Trauma is ubiquitous; about 60% of men and 50% of women will experience at least one trauma in their lifetimes, and up to 20% of these will develop PTSD (National Center for PTSD, 2016a). Many individuals and couples are not getting the help they desperately need.
Cohn (2011) sums it up poignantly when she writes:
I have never been able to make my peace with how long therapy, and trauma therapy in particular, takes. It strikes me as grossly unjust that after suffering a violent, humiliating, lonely or otherwise painful childhood, the adult might spend years of time and large sums of money just to be able to live with tranquility in the present. It also disturbed me that the therapy arrangement was such that it ends in loss: that a client would invest years, engaging in a profoundly intimate alliance with the therapist in which to heal, perhaps having a first experience of trust and safety with another person, and when the healing reaches its successful completion, by design the relationship ends. It seemed an ironic booby prize: reaching one’s goal means losing the person. . . . I wondered what it would be like if my traumatized clients could discover their safety, trust, and healing in relationships that they would then get to take home and keep. (p. xiv)
No one mode of therapy fits every person or couple. There are various reasons that some clients will not be able to participate in couple therapy. I continue to learn new approaches and combine aspects of multiple approaches in order to help survivors on their journey to healing. More than ever, I use couple therapy whenever possible to help survivors who are in long-term relationships. In the middle of the night, when a partner needs comfort, during a flashback, or when they heal and “graduate” from therapy, my goal is that they have a secure base and a safe haven present with them, a person they get to keep.
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