HEATHER DAVEDIUK GINGRICH
How does a little girl come to grips with the fact that her father, the very person who is supposed to love and protect her, hurts her and uses her sexually? What does a pubescent boy do with his mixed feelings of guilt, shame, and excitement as his youth pastor stimulates his genitals? Unfortunately, these are not hypothetical questions. Sexual abuse (SA) of children is widespread both in the United States and throughout the world. A meta-analysis of the results of 331 studies indicated that 18% of women and 7.6% of men had been sexually abused before the age of 18 (Stoltenborgh, Van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). In the United States, estimates of prevalence range from 24% to 40% of girls and 18% of boys, with the incidence of SA within evangelical circles appearing to be on par with rates in the general population (Tracy, 2011). Chances are high, therefore, that Christian mental health professionals will be faced with numerous clients who have experienced child SA.
Legal definitions of SA vary depending on the country, state, or province. Clinically, however, it is most helpful to view SA as encompassing a broad range of activities such as Bass and Davis (2008) describe. They point out that vaginal, oral, and anal rape obviously fit within the SA category, as does genital stimulation (both giving and receiving). Less apparent may be unnecessarily intrusive medical procedures, fondling of genitals under the guise of bathing, an inappropriate kiss, or unwanted touch on any part of the body. Bass and Davis state that SA does not always have to involve physical contact. SA also includes forced nudity, being required to pose for seductive photographs, hearing comments about one’s developing body, being stared at in a provocative way, being a victim of exhibitionism, or being told that all one is good for is sex.
The apparent objective severity of the abuse incident is not necessarily an accurate indicator of the subjective impact on the victim. As is the case with other types of trauma, the subjective components are usually the most salient (McFarlane & Girolamo, 2007).
Like other victims of trauma, those who have been sexually abused often struggle with the posttraumatic symptoms of intrusion (e.g., nightmares, flashbacks, intrusive thoughts and images), avoidance (e.g., constricted affect, avoidance of people or situations that could potentially trigger intrusive symptoms, dissociation), negative alterations in cognitions mood (e.g., self-blame, guilt/shame), and alterations in arousal and reactivity (e.g., hypervigilance, sleep disturbance; American Psychiatric Association, 2013). While these may be the most obvious symptoms, and those which often propel SA survivors (SASs) into counseling, SA can have even more pervasive effects.
SA, like other forms of complex trauma (see chap. 10), is a particularly devastating type of trauma in that it has a severe impact on normal developmental processes, particularly if the child is young. This is because neurological and cognitive functions are rapidly formed in early childhood, laying the necessary psychological and biological foundations crucial for subsequent healthy development (Arnold & Fisch, 2011; Ford, 2009). When these processes are blocked or interrupted as a result of trauma, the lifelong results can include impaired self-concept (Wilson, 2004), somatic dysregulation (Nijenhuis, van der Hart, Kruger, & Steele, 2004; Ogden, Minton, & Pain, 2006), disorganized attachment patterns (Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006; Pearlman & Courtois, 2005), spiritual alienation (Tracy, 2005), and dissociation (DePrince & Freyd, 2007; Gingrich, 2005). In addition, SA in early childhood is associated with dissociative identity disorder (DID; Chu, 2011), for which 1.1%–1.5% of the general population meet diagnostic criteria (Brand et al., 2016).
A closer look at early developmental processes will help to shed some light on why SA in early childhood has such devastating effects. Putnam’s (1997) model of Discrete Behavioral States (DBS) can be a helpful framework for understanding how such damage can have a lifelong impact (see various chapters in Dell & O’Neil, 2009). While the DBS model was developed a couple of decades ago, it has been supported by more recent research on attachment (e.g., Cassidy & Shaver, 2016; Lyons-Ruth et al., 2006) and psychophysiology (e.g., Shore, 2003, 2009; Siegel, 2003, 2009).
According to the DBS model, discrete, fragmented behavioral states are normative in early infancy. Newborns, for example, have no ability to regulate their emotions. When they are hungry, they may scream at the top of their lungs, their whole bodies getting into the act as they flail arms and legs with scrunched-up, red faces. But when given the breast or bottle, they immediately switch states. Their bodies instantly relax, they stop crying, and they may even make contented gurgling noises.
As children get older, they are expected to exhibit more integration between states. If, for example, a hungry five-year-old has a temper tantrum when food is not immediately available, it is likely to be seen as more problematic than if an 18-month-old exhibits the same behavior. If an adult shows such behavior, it is viewed as totally inappropriate.
With sensitive and nurturing parenting, secure attachments form which aid in the development of a more continuous, integrated sense of self and experience. For instance, if a caregiver responds to the cries of the infant, determines the reason for the crying, and takes action to alleviate the problem (e.g., by feeding, changing a diaper, or soothing), the infant learns that the parent can be counted on, which provides a sense of safety and security (Bowlby, 1988). Although the affect of infants is initially regulated externally, that is, through the responsiveness of caregivers to their needs, as children mature they develop the capacity to begin to regulate their own emotions as they learn to self-soothe (e.g., by thumb-sucking, rocking, or clutching a stuffed animal or blanket). Good parenting, therefore, not only affects attachment, and thereby the ability of individuals to function well in relationships throughout their lives, but also has a positive effect on their ability to integrate their experiences and develop a healthy sense of self.
Traumatic experiences such as SA interfere with this process of integration (Liotte, 2009). Abuse at the hands of parents, other family members, teachers, or clergy is particularly destructive because of the additional element of relational betrayal (DePrince et al., 2012; Freyd, DePrince, & Gleaves, 2007); attachment is greatly affected when the very people who are supposed to be providing a safe haven for children are the ones hurting them. Yet young children are totally dependent on their caregivers for survival. Even if the SA was not due to incest, attachment with parents may be adversely affected as children may not understand why their parents are not protecting them.
Dissociation can become an adaptive way for abused children to cope with their reality, with respect to both the trauma itself (DePrince & Freyd, 2007) and the challenges these children face in regard to attachment (Lyons-Ruth et al., 2006). For example, an incest victim who is raped in the early morning hours by her father is in the horrendous position of having to sit down at the breakfast table with her perpetrator and act as though nothing has happened. Using dissociative defenses, the child can compartmentalize the memory of being raped, effectively shutting it away, so that when she eats with her father at the breakfast table and then goes to school, she has no conscious awareness of what happened to her even minutes before. Since children dissociate easily, this process can become effortless and entirely unconscious. While nontraumatized children tend to lose their ability to dissociate as they get older (Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997), abused children may retain that capacity out of necessity (Howell, 2011). SASs are therefore more prone to dissociation, whether at moderate levels or at the severe levels that are necessary for the development of DID.
As discussed above, the DBS model provides a helpful framework for understanding how early childhood trauma such as SA interferes with normal developmental processes. One such effect is that it impedes integrative processes, resulting in the ability for SASs to use dissociation as a psychological defense to a much greater extent than individuals who do not have an abuse history.
In a sense, the DBS model gives us a bird’s-eye view of how and why victims of early childhood trauma dissociate. The following model, the BASK model of dissociation (Braun, 1988), further defines the components of discrete states and can be of great help when working with SA. BASK is an acronym that describes various components of experience or memory: Behavior, Affect, Sensation, and Knowledge. Any aspect of a particular experience can be dissociated from the rest. For example, an SAS may have no memory of an entire abuse incident or some aspect of it but may experience the affect (A) attached to the event. One SAS woke up regularly at 3:48 a.m. terrified but having no idea why. Eventually she recalled that her father regularly raped her around that time many nights during her childhood. Initially she had no conscious knowledge (K) of this series of events because the cognitive aspects were dissociated, even though she was fully aware of the emotion (A) that corresponded to it. Conversely, SASs could have full cognitive memory of an abuse incident yet display no emotion as they describe the details to you. In this case, the affect is the BASK component that is dissociated.
Sensation (S) refers to physical aspects of the experience, whether pain, pleasure, or some other aspect of somatoform dissociation. For example, SASs may experience physical pain (e.g., in the pelvic or genital area) and not know why until they make the connection to a specific abuse incident that resulted in just such pain. Dissociated sensation is often referred to as body memories in the sexual abuse literature. Behavior (B) may also be dissociated from the other BASK components. For example, some female SA survivors continually run from committed, intimate relationships with men but are unaware of the connection of this to their fears of revictimization. Another illustration is a woman who vomited every time she and her husband had intercourse, but made no conscious link between that behavior and the SA she had cognitive memory (K) of as a child. Any one of these BASK components, or various combinations, can be dissociated from the others at various times for any SAS.
For survivors who dissociate to the extent of meeting diagnostic criteria for a dissociative disorder, the same principles are in operation; it is a matter of degree. For those with DID, for instance, dissociated parts of self (DPSs) may be built around clusters of events, or smaller fragments of self may compartmentalize a particular emotion or aspect of an event. For example, most of my DID clients have had a DPS whose job was to store the rage of all other parts, because to express any anger put the individual at greater risk for abuse. Amnesia, or the K component of BASK, is common among DPSs in those with DID and is also one of the dissociative symptoms identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013).
In all cases of SA, a major part of the healing process involves reintegration of these BASK components. With counselees who have DID, the dissociative splitting is more severe, involving not only fragmentation of experience but also fragmentation of a sense of self and identity (Gingrich, 2013), which means that the process of integration will generally take longer. However, the same principles apply.
Prior to the late 1990s, the primary focus of treatment for SA was accessing and processing abuse memories. Posttraumatic reexperiencing (intrusive) symptoms such as flashbacks and nightmares were frequently triggered by attempts to work with traumatic material early on in the process of counseling and psychotherapy, resulting in further destabilization of clients. In response to these difficulties, Herman (1997) proposed a phased treatment model. This model has formed the basis of the current three-phase model that has become the standard of care for complex trauma survivors, including those with SA and DID (Brand et al., 2013; International Society for the Study of Trauma and Dissociation, 2011). This model focuses on developing safety and stabilizing symptoms (Phase 1) before attempting memory processing (Phase 2). The third phase concentrates on consolidation of therapeutic gains and healthy integration into relational networks and society. A brief summary of treatment of SA using the three-phase model is outlined below. The following summaries are based on material from my book on complex trauma (Gingrich, 2013), where more detailed descriptions of each phase of the model can also be found.
Phase 1: Safety and symptom stabilization. Paying careful attention to issues of safety both within and outside the counseling setting is crucial, as is helping such counselees to be safe from their own potential self-destructive tendencies and their posttraumatic symptoms. The full process of healing is generally long-term for SASs. Therefore, Phase 1 could potentially take many months.
Safety within the therapeutic relationship. The disruption in the formation of secure attachment relationships associated with SA not only negatively affects the development of healthy relationships in general but also makes it extremely difficult to establish a solid therapeutic relationship. Respectful, empathic reflection of content and feelings and appropriate levels of authenticity are essential skills for developing rapport.
However, safety within the therapeutic relationship goes beyond rapport in that Christian counselors must actually become safe and remain safe for their SASs. Becoming safe involves remembering that every client is unique. Therefore, what works well for one SAS may not necessarily be beneficial for a different client. SA itself is often unpredictable, with victims not knowing when they will next be assaulted. As a result, SASs can be distressed by changes for which they have not been adequately prepared. Therefore, clinicians need to give advance warning if, for example, they are going to be away, change the session time, or alter the office setting in some way.
Paying continual attention to maintaining good therapeutic boundaries is essential to remaining safe for SASs, particularly once good rapport has been established. While judicious use of touch can be a powerful tool for healing, because touch is the medium through which SA is most commonly perpetrated, it can also easily be misused with SASs. Consulting with other mental health professionals who work with SA is a good safeguard.
Safety from others. Assessing whether or not SASs are currently safe from others who have the potential to harm them is also important. SASs may not have developed the capacity to identify healthy versus unhealthy or even abusive relationships. Psychotherapists and counselors can play a role in helping SASs discern if they are in safe, healthy relationships and, if necessary, assist them in finding physical safety. Some clients with DID may have experienced ritual abuse and mind control in addition to “regular” abuse. In these cases, special attention needs to be paid to whether they are in danger of being accessed (and reabused) by their perpetrator group (see chap. 12).
Safety from self and symptoms. It is not unusual for SASs to struggle with self-destructive and suicidal tendencies that must be dealt with right from the beginning of the counseling process. Intrusive posttraumatic symptoms can also be overwhelming for both the clients who are reexperiencing the abuse and their psychotherapists who may feel caught in a losing battle of managing the associated crises. The good news is that the ability of SASs to dissociate can be harnessed by counselors to help contain both posttraumatic and self-destructive symptoms.
Use of dissociation for symptom containment. Even when SASs do not dissociate to the extent of developing DID, I have found that they respond well to techniques I originally learned in treating highly dissociative clients. I think of symptoms as cries for help, as red flags that something needs attention. SASs may not be consciously aware of the reason for particular symptoms, but I believe that some part of them is allowing symptoms to manifest. Behavioral contracting with these DPSs can result in immediate reduction of symptoms.
If Claire is a client who is experiencing intrusive visual images of SA, the negotiation around this symptom may go something like the following:
Claire, I know that these scenes that flash through your mind are very disturbing to you and are affecting your ability to function well at work. One way to look at what’s happening is that there’s a part of you that is allowing the images to come as a way of trying to help you heal, without realizing that the pictures are actually making life harder for you. Would you be willing to let me communicate with that part of you so that we could come to some kind of agreement about temporarily stopping those images?
Using language such as “a part of you” may seem strange to other types of clients, but it tends to resonate with SASs who intuitively sense that they have aspects of self or experience that are not fully integrated. If Claire consents, I will go on in this fashion:
Claire, we can do this one of two ways. I can invite all parts of you to listen in and then ask if the part of you that is allowing the images to flash through your mind is listening. You could then respond according to your internal sense of what is happening. Or, I could give the same invitation but use a short-cut way of responding through use of “yes” and “no” finger signals.
The technical name for such finger signals is ideomotor signaling (Shenefel, 2011). I demystify the process by explaining to clients that use of the finger signals is just a way to bypass their conscious, cognitive processes and allow a hidden part of them a safe way to communicate. If Claire chooses to go this route, we would agree on which finger means “yes” and which indicates “no.” I would then describe how the relevant finger would twitch a little when responding, without Claire having to make a conscious decision about which is the right answer. Claire and I would also come up with a “stop” signal so that if for any reason she could not verbalize her desire to pause or terminate the process, she could still communicate that wish to me. Ideomotor signaling is merely a tool to allow easier initial access to a dissociated aspect of the self of the SAS. The negotiation process is not dependent on its use, although clients often prefer it once they have experienced its benefits.
If Claire has decided she is willing to give it a try but is concerned that it will not work, I respond, “This is just a technique that I’ve found to be helpful with many of my clients, Claire. If nothing happens, nothing happens! In that case we’ll just try something else.” This generally alleviates any pressure to perform. I then go over again what Claire can expect:
Claire, we have already decided on “yes,” “no,” and “stop” signals. In a few minutes I’ll invite you to relax. Many people find that it’s easier to concentrate if they close their eyes, but you can decide whether to close them or not. You will be able to hear what I’m saying at all times and are free to ask questions or stop the process at any point. I will then invite all parts of you to listen in, after which I will introduce myself, go over the finger signals once more, and go from there. [Note: I always introduce myself because I do not know how dissociative the client might be and whether or not all parts of the client have been privy to my prior discussions with Claire.] Do you have any other questions?
If Claire is ready to proceed, I will begin. After ensuring that the finger signals are understood, I will then say, “Claire has been telling me that she has been seeing a lot of images of a little girl getting hurt. Is the part of Claire who knows about these images listening in?” If there is no response, I will wait for a minute or two. If nothing happens, I will ask if there is a reason that there is no reply in an attempt to find out whether concerns exist have not been previously expressed. If there is an initial “no” response, I will ask the rest of Claire to extend the invitation internally to listen in, offering further explanation of why I am seeking contact. Sometimes this alleviates any fears, and that part of the client is then willing to have contact. If the initial response is a “yes,” I will also explain my reasons for wanting to communicate. For example:
I know that the images that Claire is seeing have been allowed for a reason. I want you to know that Claire now understands that you want to get her attention. That message has been received. The problem is that this is not a good time for Claire to deal with the content of those images. Claire needs to be able to work and attend school, and the images are making it hard for her to do that. She will need some time to stabilize. However, Claire is aware that she needs to deal with those images. Would you be willing to put those images away somewhere inside where Claire can’t see them until some point in the future when Claire is better able to make use of them?
Often there is a “yes” response once that part of the client understands that he or she has been heard. I then debrief the entire experience with Claire. I let her know that this type of symptom containment is a temporary measure. My experience has been that such symptoms either totally disappear for a period of time or are greatly reduced.
A similar process can be used for other intrusive, recurring symptoms such as nightmares or dissociated affect. Self-destructive or suicidal behavior can be negotiated in the same way. The key is to make the contract with “all parts of Claire” so that there is no sabotage from other DPSs.
A DPS, whether an alter personality of a DID client or a dissociated aspect (BASK component) of an SAS who does not have DID, may initially present as antagonistic or even highly destructive to the client (e.g., actively suicidal, self-harming). In the DID literature such DPSs are often referred to as persecutor alters for this very reason.
Most often this hostility masks fear or is a misguided attempt to protect the client. For example, if a brutally raped child is told that she will be killed if she talks to anyone about the SA, a DPS associated with that trauma may believe that revealing the SA in therapy may result in her death. Ironically, in the DID client, the DPS may not understand that all dissociated parts of the client share the same body, so that the attempt to “silence” the one revealing the “secret” in therapy will result in her own death (and the death of all the other DPSs). Psychoeducation about the process of dissociation and the client’s own dissociated personality structure may, therefore, need to precede successful negotiation around safety from self or resistance to discussing the abuse. I tend to talk to clients about dissociation as being on a continuum (see Gingrich, 2013) rather than prematurely share with them a DID diagnosis, which could potentially be destabilizing.
When contracting does not work well, it may be because the negotiations have not been done with the most appropriate DPS. For example, there may be some DPSs that are very concerned about suicidal behavior and will easily negotiate a no-suicide contract. But if they are not the DPSs that are feeling suicidal, the contract may be meaningless.
Other ways of managing symptoms. Of course, there are more traditional ways of helping SASs with their symptoms. Cognitive-behavioral techniques such as systematic desensitization and relaxation training, dialectical behavior therapy, and use of mindfulness can certainly be helpful. Courtois and Ford’s (2009) excellent edited book, for example, contains chapters on multiple theoretical approaches to working with SA and other forms of complex trauma, including how to manage symptoms. However, I have focused primarily on making therapeutic use of the dissociative capacities of SA clients because the positive results are so immediate and are not as well known.
Phase 2: Processing of traumatic memories. The processing of horrendous SA memories is difficult for both clients and psychotherapists. Appropriate timing is essential for entering this second phase. Clients should be stable and have a good support network in place that can help sustain them through this work.
The BASK mode is particularly helpful during Phase 2 work. As mentioned earlier, for a particular memory to be fully integrated, all four BASK components need to be addressed. It is common for SASs to not have cognitive knowledge (K) for some or all abuse incidents. However, even when clients have never had amnesia for a particular traumatic experience, the affect (A), physical sensation (S), and behavior (B) associated with that knowledge (K) may be dissociated from it. Therefore, memory processing involves not merely accessing and talking about a particular memory at the cognitive level (K) but addressing all BASK components associated with it.
Accessing memories. Symptoms are clues to accessing blocked memories. Nightmares, full or partial flashbacks, intense emotion (e.g., anxiety, depression) for no apparent reason, seemingly random physical ailments, or confusing behavior can all be evidence of dissociated BASK components. The key to accessing the memory is to access the part of the individual who knows what the symptom is about. The procedure is similar to that which I described for symptom containment. I begin by getting consent from the client, deciding whether to use verbal responses or ideomotor signaling, going over the finger signals (if applicable), asking all parts of the person to listen in, introducing myself, and then asking if the part of the person who understands the symptom is available.
Let’s say that Claire presents with the same symptom as before, that is, of being disturbed by visual flashbacks. However, rather than being in Phase 1, she is now in Phase 2 of the healing process. In this situation I would go through the same steps as before, but rather than asking that the symptom be compartmentalized, I now want to seek permission to process the content of the images. I will assume that preliminary steps have been taken and that through ideomotor signaling I have confirmation that I have contact with the part of Claire who understands what the flashbacks are about. I would proceed as follows:
It was about a year ago that you agreed to keep Claire from seeing these images and you kept them away until recently. Thank you for keeping your agreement. Not seeing those images all the time really helped Claire get stronger, and she is doing much better now. I’m wondering if you think that this might be a good time for Claire to take a closer look at those images.
If there is a “yes” response, I would continue: “It is still important for Claire not to be overwhelmed. So we would need to take a look at one image at a time and go at a pace that Claire is comfortable with. Are you OK with that?” The same kind of procedure can be used whatever the problematic symptom might be (e.g., sound, smell, full flashback, nightmare, intense emotion).
It is essential to lay appropriate groundwork for memory processing. Once the decision has been made to enter Phase 2, clients sometimes want to dive into the process in an attempt to get it done quickly. When the necessity of careful pacing is not understood by the entire person, the result can be like opening Pandora’s box—that is, memories can flood to the surface leaving the client feeling totally out of control and destabilized.
Even if Claire feels that she is ready to begin processing a particular memory, and the part of her that has allowed the visual images to come indicates assent to begin memory processing, I would also ask “all of Claire” if any part of her has concerns about going forward. If any apprehension is indicated, I would ask for clarification and, on the basis of the information given, either come to the conclusion that the timing is not good after all or continue the dialogue until all parts of Claire are comfortable continuing. Ideomotor signaling can be used only when asking closed questions, so any ongoing discussion requires verbal responses. Generally, this is not a problem once initial contact has been made with the relevant DPS.
Processing the SA memory. It is important for the SAS to be able to put together a cohesive trauma narrative (Siegel, 2003; 2009). So that there are no gaps in the narrative, and in order to combat the intense shame with which SASs inevitably struggle, clients should be encouraged to share every detail of the abuse memory from beginning to end. I used to think that by allowing my clients to talk only about the key aspects of abuse incidents, I was protecting them. In retrospect, I believe I was actually defending myself from having to face the full horror of what they had experienced. However, when there have been many similar incidents over time with the same perpetrator, groups of memories can sometimes be worked through simultaneously. All DPSs that hold similar memories, or aspects of specific memories, would have to be present (i.e., coconscious), adding in any nuances that are specific to their particular memories, even if one DPS shares the primary narrative.
While all of the BASK components of the SA memories need to be reexperienced to some degree in order for integration to occur, memory processing is not the equivalent of catharsis. There will be some tension between the client being “back there” and reliving the experience, and being in the here and now with the counselor. If clients begin to get lost in their memories, psychotherapists can help to keep their clients grounded by reminding them of where they are and what is happening in the present. For example, if Claire, in the middle of describing what she sees in her visual flashbacks, suddenly stops talking and looks terrified, I would say something like the following: “Claire, focus on my voice. It’s Heather. You’re in my office. It’s 2017. I would like you to leave where you are inside and come back to the present. Feel the fabric of the chair you’re sitting on with your fingers. Open your eyes and you will see the green paint on the walls and the purple color of the shirt that you’re wearing.”
Sometimes encouraging the client to move their hands or feet or stand up can also help. Usually this is all that is necessary. However, if Claire is still unresponsive, I would try a different tactic. Using a firm yet gentle voice, I would state, “Claire, I’m going to count to three, and when I reach the number three, you are going to open your eyes and come back to my office. One . . . you are beginning to come back . . . two . . . you are almost here . . . and three . . . you can open your eyes.” On one occasion, as a last resort I snapped my fingers to get the client’s attention, but that produced a startle response that was not ideal.
Once Claire is fully back in the present, we will process what happened and decide whether we should continue with the memory or wait until the following session. If we agree that putting it on hold for a week is a better option, Claire’s dissociative abilities can again be utilized to keep her from being retraumatized during the week. I could give Claire the option of temporarily “storing” the memory in my filing cabinet or placing it in an imaginary locked container inside of her. It is important that all DPSs understand that the memory needs to be compartmentalized between sessions.
If working through a particular memory feels too overwhelming for the counselee, the emotional intensity can be lowered by using distancing techniques. For example, SASs can be invited to visualize a TV screen complete with a remote control that will enable them to stop, play, rewind, fast forward, pause, and mute the action. The affective element (A) can be processed once the cognitive knowledge (K) has been gained.
While it may be tempting to extend a session if a memory is not completely processed, it is generally better to keep to the agreed-on session time so that the client knows what to expect. On occasion a longer session can be prearranged for a particular purpose. But memory processing is intense, and there is nothing to be gained by both client and psychotherapist leaving a session totally depleted. Allow sufficient time at the end of each session to debrief with clients and ensure that they are grounded enough to get home safely.
Avoiding suggestibility. Much research has been done on the nature of memory since the False Memory Syndrome Foundation, formed in 1993, made claims that therapists could implant false memories of sexual abuse, and that repressed memories, that is, amnesia for sexual abuse, were not possible (Hyman & Loftus, 1997). Research findings have shown conclusively that it is possible to have memory blocks for incidents of trauma and sexual abuse (Brown, Scheflin, & Whitfield, 1999). Results have also indicated that memory is not infallible, that it is subject to distortion (Chu, 2011).
For this reason, those working with SASs have to be particularly careful not to ask leading questions. Open, general questions that put the onus on clients to fill in the missing pieces need to be standard practice. For example, if the client says, “I see a dark figure coming through the door,” potentially suggestible responses could be “Is it a man?” or “Is it your uncle?” or even “Could it be an evil spirit?” Nonsuggestive interventions could be “Tell me more about this figure” or “Can you describe what you are seeing?” or even an empathic reflection of feeling such as “You seem really scared right now.”
We cannot know for sure that what our clients remember is accurate in every detail. Perpetrators sometimes use drugs, tricks, or lies, which can all distort perception (Miller, 2012). However, for healing to take place, it is the subjective experiential reality of the client that is important. This can be explained to clients in a way that does not invalidate their experience but acknowledges that the only way to know for sure what happened is if there is corroborating evidence (e.g., medical records, court documentation, or eyewitness accounts of others). The most helpful stance that the counselor or psychotherapist can take is to process SA memories as though what clients remember is true, while retaining some healthy skepticism because of the fallibility of memory.
Working through intense emotions: General guidelines. A significant aspect of Phase 2 work is helping clients process the intense emotions surrounding their SA experiences. The A component of the BASK model is one aspect of this work. However, strong emotions are not limited to occasions in which SASs are remembering how they felt at the time that they were being abused; they also arise as a result of confronting the overall impact these traumatic events have both in the past and in the present.
Some SASs have dissociated their emotions to such an extent that they are easily overwhelmed by awareness of having any degree of affective experience. At the other extreme are those who have had difficulty controlling emotional impulses. The key is to strike a balance between encouraging increased awareness of affect so that it does not remain dissociated and maintaining some control of the process.
Just as dissociation can be used to help contain posttraumatic symptoms in Phase 1, so the ability of SASs to dissociate can be useful in Phase 2 affective work. For example, if a client has expressed powerful anger during the session that has not been fully worked through, the anger can be figuratively stored away between sessions so that relationships in the outside world are not damaged through inappropriate outbursts.
My basic rule within sessions is that neither I nor the client is harmed and that my office is not damaged. Within this framework a lot is permissible in terms of emotional expression. Christian clients, in particular, may be hesitant to acknowledge the strength of what are often labeled negative emotions (e.g., hatred, anger) out of fear that they will be dishonoring God. I remind these individuals that God already knows what emotions they are harboring, so that even if they attempt to deny their existence, they are not fooling God.
I find the analogy of an infected wound helpful. Sometimes a deep cut can heal over on the surface while festering underneath. Such wounds may need to be lanced, allowing the pus to drain, after which they can be cleaned and disinfected so that proper healing can occur. Emotional wounds are similar. Intense, disturbing emotions may need to come to the surface and be worked through so that the wound can properly heal.
Christian SASs who are struggling with what a “Christian” response to their abuse could look like may also be referred to Scripture. The psalmist expresses a range of deeply felt, raw emotions such as desire for revenge (e.g., Ps 10, 28, and 55), despair, and hopelessness (Ps 42). Christ himself expressed agony in the Garden of Gethsemane as he wrestled with his imminent crucifixion (Mk 14:32-36). Individuals who have been sexually abused can often identify with such feelings.
Dealing with specific emotions. While a wide range of emotions can come up for SASs, some are commonly experienced. The following are examples of groups of emotions that are often related:
Mourning: denial, anger, and depression. There are many losses for SASs to mourn: loss of childhood innocence, the recognition that they were not a loved child, loss of hope that their parents will ever love them, or coming to grips with lost relational or career opportunities because of their symptoms. For survivors who had amnesia for their abuse until later in life, there has to be readjustment of their whole sense of life history and, therefore, identity. While healing can open up new doors of possibility, nothing can take away the years, relationships, or opportunities that already have been lost. It is no wonder that SASs, even after many years of counseling, go back and forth between disavowal of the abuse and depression that accompanies the realization of the truth. These losses need to be identified and permission given to grieve them.
Shame. The sexual nature of the trauma perpetrated against them makes SASs particularly vulnerable to struggling with shame. Shame is painfully apparent when clients have difficulty making eye contact. Shame can serve as a barrier to entering Phase 2 work because of the related fear of exposing oneself to someone else (i.e., the counselor). However, the nonjudgmental response of the psychotherapist can be immensely powerful in decreasing shame. After successfully testing the waters with their counselors, SASs often find it helpful to continue to “break the silence” by sharing their abuse histories with others. Sometimes they need guidance in how much to reveal and to whom, so that they do not reveal such personal information indiscriminately, with damaging consequences.
Self-hatred. Related to shame is self-hatred. SASs tend to blame themselves for their abuse, believing that there is something inherently bad in them that is deserving of punishment. While it is true that we are all sinners (Rom 3:23), it is not true that SA is a legitimate form of love, affection, or discipline. Self-blame is further encouraged by perpetrators who use it as a way to keep their victims from reporting the abuse. The empathic, nonjudgmental acceptance of counselors who see their SASs as valuable creations of God will go a long way in breaking through these distorted self-perceptions. Christian clients often are aware of the Bible verses that talk about our worth as children of God. However, this truth seldom penetrates their whole beings, being relegated instead to cognitive, head knowledge. However, being in the presence of a person who knows their worst secrets and accepts them anyway is often an important step toward recognizing that Christ, too, loves and values them.
Fear of abandonment. SASs were emotionally abandoned as children by those who were supposed to protect them, a relational pattern that often replays itself throughout their lives. Seldom having developed a secure attachment style, SASs bring their relational insecurities into the therapeutic relationship. As a result, these counselees are extremely sensitive to perceived rejection and tend to have deep-seated fears of being abandoned. Consistency over time, sometimes many months or years, is the primary way to combat abandonment issues. The counselor taking vacation times, going to conferences, and canceling sessions for any reason (including illness, surgery, weather, childbirth, or family crisis) and virtually any change affecting the structure of the sessions (e.g., change in office, appointment times, or fees) can be expected to stir up fears of abandonment. These should be anticipated and care should be taken to prepare clients ahead of time for any changes.
Anxiety, fear, and terror. SASs have had a lot to fear. During memory processing, some of the terror that survivors felt as children in the midst of a particular abuse incident resurfaces, or the anxiety that they experienced while anticipating the next attack is relived. In their adult lives, these fear responses are commonly dissociated from their source (A of BASK). While relaxation exercises, systematic desensitization, and other behavioral or cognitive-behavioral techniques can be useful in helping to work toward alleviating these feelings, at times they are minimally helpful. In some of these instances I have found that it is a child DPS that is the one feeling the terror. A clue that the anxiety stems from dissociated affect can be to ask clients, “How old do you feel when you are so afraid?” Often they are surprised to realize that they do not feel like an adult. This can become a steppingstone for further memory processing.
Antianxiety medication can be helpful for clients whose anxiety is so high that attempts to compartmentalize it are not effective. If counselees are too overwhelmed, they will not be able to make good use of therapy. Toward the end of the therapy process, SASs will often find that they no longer need to take antianxiety medication on a regular basis.
Integration of self. When a particular memory is processed in such a way that all the BASK components are addressed, a more integrated memory is a result. When a number of memories are processed, along with the emotions that arise in reaction to these memories, integration of self is furthered. A good analogy might be a jigsaw puzzle in which many of the puzzle pieces have been cut up or torn into smaller parts. In order to complete the puzzle, one must first put each puzzle piece back together before finding its place in the puzzle as a whole. For SASs whose abuse was not chronic, or for those who were abused at an older age, the puzzle may have been relatively intact even before entering treatment. Others, whose SA resulted in DID, may have entered therapy severely fragmented, with little of the puzzle intact. In instances where there has been greater use of dissociation to keep aspects of self and experience compartmentalized, integration of self will generally take longer.
Phase 3: Consolidation and resolution. SASs may have experienced major upheaval during Phase 2. Their view of their own life history, and therefore their overall sense of identity, may have been severely challenged. This is particularly true of survivors who have DID; in fact, identity confusion is considered a DSM-5 (APA, 2013) dissociative symptom area. While much work will have been done in Phase 2 to grieve these losses as well as begin to wrestle with a new sense of who they are, consolidation of these changes is the core component of Phase 3. It is also not unusual for emotions that were supposedly worked through in Phase 2 to reappear in Phase 3 as they are examined through the eyes of a more fully integrated individual.
Learning new coping strategies. In Phases 1 and 2, the dissociative abilities of SASs were used to help them manage overwhelming emotions. However, by the end of Phase 2, integration of self and experience have progressed to the extent that counselees no longer have the same capacity to dissociate. Therefore, they need to develop new ways of dealing with their feelings. This is where counselors can draw on everything they know about helping clients regulate their affect (e.g., cognitive-behavioral techniques, relaxation training, dialectical behavior therapy, mindfulness).
Navigating changing relationships. As SASs get healthier, they will likely experience increased tension in many of their former relationships. In a marriage, for example, the SAS may have previously been in a dependent role, a position that may be challenged as the survivor gains strength, desires a more equal footing, and finds his or her voice. The spouse of a DID client may have developed relationships with various DPSs (e.g., child personalities) and may consciously or unconsciously sabotage continued growth. Similarly, parental roles may change as healthier counselees either increase their involvement or change how they relate to their children.
If similar changes can be navigated within friendships, these relationships may be strengthened. However, counselees may discover that they have emotionally outgrown their former friendships and struggle with how to develop new relationships on a different basis. This may also apply to their relationship with God as well as relationships within the body of Christ. Counselees may find themselves searching for a new place to worship, recognizing that their theology no longer fits with that of their current church, or that it no longer meets the spiritual, emotional, or relational needs it once did. The process can be particularly painful when former church congregations have invested a lot of time and energy in the SAS and have been helpful at an earlier place in the journey of healing.
Relationships with members of their family of origin may be tumultuous, particularly if incest was involved. SASs who choose to explicitly address the issue of their abuse with family members risk rejection and even rage from those who are unwilling to acknowledge the abuse or who blame the victims for it. Whether or not survivors choose to confront their perpetrators, at the point in time when the abuse is no longer kept secret, family members are forced to choose sides.
The process of forgiveness. One of the difficulties in looking at forgiveness is that it is defined in various ways by Christian authors. Sells and Hervey (2011) summarize the literature on forgiveness, particularly as it is relevant to SA. I have found Tracy’s (2005) category of psychological forgiveness particularly applicable for counselors and psychotherapists. He suggests that for survivors psychological forgiveness involves both letting go of hatred and revenge and extending grace to the ones who wronged them, perhaps by praying that their perpetrators find healing. Psychological forgiveness does not necessitate reconciliation of the relationship between victim and perpetrator. Reconciliation is often not possible because the perpetrator either denies or minimizes the abuse and/or there is risk of further victimization of survivors or their children. The deep-seated dysfunction of the SA perpetrator is often not understood by Christian pastors or laypeople, who may exert undue pressure on the SAS to quickly reconcile with a perpetrator who is neither fully repentant nor safe (Anton & Fortune, 1992).
Many of my Christian SASs have expressed concern that I too will push them toward premature forgiveness, when they cannot envision extending forgiveness toward their perpetrator as even a possibility despite what is exhorted in the Bible. The approach I take is to talk about forgiveness as a process that will take time. I remind them that God knows them and loves them and will not expect the impossible.
While SASs can make a decision that they want to forgive and can begin the process early on in treatment, I do not believe that forgiveness can be complete until some point in Phase 3 work. Prior to trauma processing, SASs do not wholly understand what has been perpetrated against them and the full impact of the abuse on their lives; therefore they do not entirely comprehend what they are attempting to forgive. I have found that forgiveness is generally a natural outcome of the healing process for those who are seeking spiritual and psychological wholeness.
Ending the therapeutic relationship. Many SASs will never have experienced the healthy ending of a relationship. Terminating therapy well, therefore, can serve as a model for future good endings. The longer the counseling relationship, the greater the period of time that should be devoted to termination issues. Early on in Phase 3, the thought of ending the therapeutic relationship will likely be totally overwhelming to SASs. However, as SASs become more comfortable with who they are as people, as therapeutic gains are consolidated, and as issues of changing relationships, emotional regulation, and forgiveness are resolved, they will become more comfortable with the idea of termination.
I often space out appointments in the last few months of counseling so that SASs have a chance to gain confidence that they can cope between sessions without decompensating. If we have met once a week, I will suggest going to every other week, then every third week, and so on, with the stipulation that clients can ask for additional sessions between times if they feel the need. I also keep the door open to the possibility of future sessions. Having these options available helps to alleviate anxiety, so that extra sessions are seldom necessary.
The ending of such an intense, long-term relationship involves loss for both SASs and their therapists. It is tempting to make exceptions that counselors would not normally consider with regard to ongoing contact with SASs. While receiving updates from former clients from time to time may be appropriate, it is important to keep in mind ethical guidelines with regard to any kind of ongoing relationship. Clients will often hope that a mutual friendship can develop after the formal counseling relationship is over. However, because of the power differential between therapist and client, it is highly unlikely that a fully mutual relationship is possible after the kind of intensive counseling necessitated by SA, and it is generally considered unethical.
Some SASs come into therapy with a strong faith in God and an ability to benefit greatly from explicit use of spiritual resources. The challenge is to not err either on the side of being overly cautious or on the side of being overly presumptuous about what might be helpful as it relates to spirituality. Discerning the difference is a matter of developing good clinical judgment and spiritual discernment and then carefully testing the waters with informed consent from the client.
There are SASs who report full healing solely through the prayer ministries and the relational support of their church. I have no reason to doubt these testimonies. God is the source of all healing, with psychotherapy being only one vehicle. However, many survivors, both Christian and not, have distorted views of God and would not benefit from prayer ministry of any kind. They often wrestle with how God could love them yet not have rescued them from terrible abuse. It is particularly difficult for those who were abused by their own fathers to view God the Father as anything but punitive and abusive.
The most therapeutic responses toward SASs who are struggling with how God could have allowed them to suffer so much are often either empathic responses (e.g., “It just hurts so much to know that God didn’t somehow stop the abuse from happening, even when you pleaded with him so desperately to rescue you”) or responses that combine empathy and genuineness (e.g., “I feel so sad thinking about you as a little girl crying out to God for help and feeling so abandoned by him when the abuse didn’t stop”).
When counselees are not given the simplistic answers they may have come to expect of Christians, but instead are given permission to openly admit their doubts and fears with respect to their relationship with God, I have found that they can often begin to see where God was at work in their lives all along. As hostility toward God lessens, it may be more appropriate to respectfully offer to use Scripture to help confront their distortions about God or to bring comfort in times of distress.
I believe that prayer is an essential aspect of the healing process for SASs. Christian counselors should pray for their clients outside session time, as well as silently pray for wisdom and discernment as the session progresses. While in-session verbal prayer can be helpful, it needs to be used with caution and the full, meaningful consent of the client. The key is to recognize that prayer, in the context of therapy, is a specific type of intervention and needs to be processed with the client as any other intervention would be (Chapelle, 2000; McMinn, 1996; Tan, 1994, 1996). For example, discussions regarding who should pray (i.e., client, counselor, or both), what the focus of the prayer should be, and the timing of the prayer all need to be part of the decision-making process. If explicit prayer does happen, it needs to be debriefed with the client.
Specialized forms of prayer, such as inner healing prayer (e.g., Hurding, 1995) or Theophostic Prayer Ministry (Smith, 2005; now called Transformation Prayer Ministry, www.transformationprayer.org), are generally used by lay counselors or prayer ministers. However, they could potentially be used in Phase 2 by mental health professionals as part of memory processing, particularly if integrated within the fabric of the therapy process as a whole. Again, informed consent is necessary, and such an intervention must be carefully processed and debriefed.
Some SASs report ritualized abuse by Satanic cults or secret societies (see Gingrich, 2013; Miller, 2012; and chap. 12 in this volume for more information about dealing with ritual abuse as well as the demonic). While the three-phase model still applies to these clients, there are additional issues to consider, including being triggered by symbols of Christianity.
Christians in general do not understand dissociative symptoms. Therefore, in some church contexts or circles, SASs who have DID are thought to be particularly sinful or are accused of being demon possessed. Whether or not there is any validity to these charges, great damage can be done to SASs who are forced to undergo deliverance or exorcism rituals. Counselors should not be surprised when this subject is broached in therapy. Highly dissociative SASs may have already been through traumatizing attempts to rid them of evil spirits, which then become additional trauma to process in Phase 2, or they may be feeling pressured by their faith communities to undergo such procedures.
Working with SASs can take a physical, emotional, and spiritual toll. Listening to horrendous abuse narratives week after week can lead to vicarious traumatization, a condition in which counselors can manifest trauma symptoms as a result of conducting psychotherapy with trauma survivors. Practitioners must, therefore, find ways to build physical, emotional, spiritual, and professional resilience against becoming traumatized themselves (see Gingrich, 2013, and chap. 4 in this volume for more details).
While counseling or psychotherapy can be of immense help in the healing process of SASs, it is not enough. Churches play a necessary role. Outlined below are some examples of how churches can play a part in the healing process.
Education. The posttraumatic and dissociative symptoms of SASs can be easily misinterpreted and misunderstood. Therefore, it is important for pastors, lay leaders, lay counselors, life coaches, spiritual directors, and other members of church congregations to be educated about SA and DID. Counselors can offer seminars, consult with church leaders, or point individuals to books and other resources. Some organizations exist specifically to help minister to SA and highly dissociative individuals and to train those who desire to be of help to them (see Gingrich, 2013, for more information about organizations that train Christians to work with SA, as well as other resources that are available.)
Churches can help to prevent child SA from occurring in the first place through screening volunteers (including running background checks), developing protocols to reduce the possibility of abuse, and training staff and volunteers to recognize signs of child abuse. There is also Christian education curriculum that helps teach children about abuse (e.g., FaithTrust Institute, www.faithtrustinstitute.org). SA can be addressed from the pulpit as well.
Emotional and spiritual support. Support for SASs can be offered either formally or informally. Formal support can take the form of groups such as Celebrate Recovery, other modified 12-step programs, or groups specifically designed for SASs. Some churches have a lay ministry program in place in which lay counselors, mentors, prayer ministers, or life coaches are available to wounded people.
Often the best kind of support is informal. Ultimately SASs need to be surrounded by caring, safe people who will accept them wherever they are in their healing process without judgment. There can be danger for SASs from people who push too hard and fast for healing, perhaps expecting easy fixes through prayer, deliverance from demons, or application of Scripture.
People sometimes think it is strange that my favorite course to teach is Counseling for Trauma and Abuse and that the clients I most enjoy working with are adults who have been abused as children, particularly those with DID. What has kept me in this field for over 30 years? It is the privilege of walking with such deeply wounded individuals and witnessing the miracle of healing that God performs in their lives. There is hope for even the most fragmented and damaged survivors of SA, as well as hope that those of us in helping roles can be sustained in the midst of such difficult work.
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