The classic definition of “trauma” provided by Bessel Vander Kolk (1987) includes both the dramatic nature of an event as well as the individual’s ability to cope. Despite our capacity to survive and adapt, trauma can alter one’s psychological, biological and social equilibrium to such a degree that this extreme event interferes with all other experiences including any appreciation of the present (Vander Kolk 1995).
Not all individuals who experience trauma suffer from Post-Traumatic Stress Disorder (PTSD) however. The American Psychiatric Association (2000) notes that to assign a diagnosis of PTSD, an individual must exhibit one or more of the following: The traumatic event is persistently re-experienced (through recurrent thoughts, dreams and/or flashbacks); Persistent avoidance of stimuli associated with the trauma (through efforts to avoid thoughts, feelings, activities, places or people that might arouse recollections of the trauma); Persistent symptoms of increased arousal (such as sleep disturbance, difficulty concentrating, anger outbursts, hyper-vigilance, or exaggerated startle response).
In addition, various factors affect the duration and severity of the trauma response including: severity of the stressor, developmental level, genetic predisposition, social support system, prior traumatizations, and re-existing personality.
For children who have experienced a form of trauma, (e.g. sexual abuse) the trauma disrupts and sometimes destroys the sense of an “intact self” (Garfield & Leveroni 2000); the child’s sense of self lacks the esteem for regularity psychic structure (Stolorow & Lackmann 1980).
Sexual abuse continues to emerge as a major form of child abuse in our society today. Childhood sexual abuse may be defined as contacts or interaction between a child and an adult when the child is being used as an object of gratification for the adult’s sexual needs (de Vine 1980). Sexual abuse of children by an adult is victimization that occurs within the power differential of a relationship between perpetrator and victim. When this contact happens within the family system (e.g., father, mother, brother, sister, cousin, stepfather), it is defined as incest. Childhood sexual abuse also often happens outside the family system, e.g., close neighbor, teacher, babysitting) and involves similar dynamics, such as denial, repetitiveness, betrayal and trauma (Jones 1996).
Events which traumatize are not only a violation of the child; they also result in a violation of his or her basic sense of how the world works. The trauma destroys self-concept as well as the child’s assumptions of others and the environment. (Janoff-Bulman 1992; Pearlman & Soskvitne 1995).
Fortunately, treatment exists and often works for many of these children! During therapy, survivors of sexual abuse trauma are encouraged to come to terms with what happened in the past, as they learn to develop effective and more successful coping strategies (Knight 2006). Primarily, the therapeutic relationship is both a means through which recovery and healing occurs and is a significant component of the healing process.
Trauma Based Cognitive Behavioral Therapy (CBT) has been proven effective in working with children who are suffering from Post-traumatic Stress Disorder due to sexual abuse (Cohen, J. A., & Mannarino, A. P. 1998). Furthermore, Trauma Based CBT has been designated a model program by the National Registry of Evidence Based Programs and Practices and the Substance Abuse and Mental Health Service Administration (SAMSHA). Research has also indicated that Trauma Based CBT is effective in working with children who are suffering from multiple traumas, as well as depression, and behavioral problems (Cohen, Judith A., Anthony P. Mannarino, Lucy Berliner, and Esther Deblinger 2000). Although Trauma Focused CBT is structured and implemented in a series of segments, it is adaptable to meet the individual needs of the client. As noted above, the most important factor to any type of treatment is to create a positive therapeutic alliance with the client. (Krupnick, SM Sotsky, I Elkin, S Simmens, J. Focus, 2006). Trauma focused CBT has been critical in helping three of these children at South Shore Child Guidance Center heal from the effects of Post-Traumatic Stress Disorder due to sexual abuse.
As mentioned earlier, Trauma Based Cognitive Therapy is implemented in segments. These segments include; psychoeducation, stress management, affect expression and modulation, cognitive coping, creating the trauma narrative, cognitive processing, behavior management training, and facilitating parent and child sessions (Cohen, J.A., Mannarino, A.P., & Deblinger, E. 2006).
Children who are sexually abused often blame themselves for the abuse. Psychoeducation is essential in the therapeutic process in order to clarify inappropriate information given to the child by the perpetrator.
The following vignettes illustrate 3 cases from South Shore Child Guidance Center’s clients.
“Emma” was referred for treatment due to suffering from PTSD since she was sexually abused by her mothers’ boyfriend at the age of nine. Initially, she was provided psycho education regarding the different types of trauma, causes of trauma, effects of the trauma, as well as normalizing the resistance to discuss sexual abuse. Furthermore, psycho education should entail the discussion of the correct names of body parts, as well as safety planning to avoid re-victimization. Throughout treatment, “Emma” learned methods to reduce stress, such as deep breathing techniques and was provided a meditation CD in order for her to practice at home. She recorded the times that she practiced the deep breathing techniques on paper. “Emma” was also able to teach her mother these techniques which she learned during session. “Emma” was also introduced to the method of progressive muscle relaxation, as well as “thought stopping.” She reported that these techniques were useful when she had flashbacks of the abuse. “Emma” learned during treatment the importance of being able to identify emotions and eventually developed the ability to verbalize them.
Many children develop negative behaviors in order to cope with the negative feelings that are triggered by thoughts of the sexual abuse. Therefore, it is crucial that these children are given alternative methods to work through these feelings. Developing a Trauma Narrative is one strategy to work through these feelings. (Judith A. Cohen, M.D., Esther Deblinger, Ph.D., and Anthony Mannarino, Ph.D, 2006). Initially, “Emma” was resistant in writing the details of the event, however, she utilized the skills she had learned throughout the course of treatment in order to reduce the anxiety. The goal is to reduce the impact of experiencing negative emotions when thoughts of the abuse arise (Judith A. Cohen, M.D., Esther Deblinger, Ph.D., and Anthony Mannarino, Ph.D. 2006). “Emma” shared her story of abuse in writing during therapy, and eventually with her mother. She verbalized a sense of wellbeing in the weeks following the trauma narrative. She is now able to communicate openly about her history of sexual abuse.
“Tracy” was an eight-year-old youngster when she began treatment at South Shore Child Guidance Center due to being sexually abused by a family member. “Tracy” suffered from flashbacks due to the abuse. She suffered from depressive symptoms, anxiety, and insomnia. Once “Tracy” mastered the stress management techniques learned in Trauma Focused Cognitive Behavioral Therapy she showed a major improvement in her level of functioning. She was able to write the trauma narrative and verbalize her feelings without experiencing severe anxiety. She suffered from shame and blamed herself for the cause of the trauma. These issues were explored during the course of treatment through the method of cognitive processing. Cognitive processing works to challenge false or unhealthy cognitions. (i.e. “I am a bad person”) (Judith A. Cohen, M.D., Esther Deblinger, Ph.D., and Anthony Mannarino, Ph.D. 2006). “Tracy” was able to develop a more positive self-image and maintain healthy relationships in treatment. She graduated high school and is attending college. Although she remembers the sexual trauma, she is no longer paralyzed by her negative emotions associated with it.
“Danielle” was referred for therapy due to suffering from sexual abuse from her grandfather. Danielle was six years old at the time of abuse. “Danielle” was manifesting symptoms of highly sexualized behavior, impulsivity, as well as Post Traumatic Stress Disorder. According to the family, “Danielle” was known as a bully towards other children and did not have any friends. While learning the technique of affect expression and modulation, “Danielle” developed ways to identify her feelings and express them more appropriately (Judith A. Cohen, M.D., Esther Deblinger, Ph.D., and Anthony Mannarino, Ph.D. 2006). Throughout the course of treatment, “Danielle” began to demonstrate more appropriate behaviors with her peers at school. She was invited to a birthday party for a friend in class. Her parents were able to experience positive family functions. “Danielle” is currently doing well at home and at school and is no longer engaging in acting out behavior. Throughout the course of treatment at South Shore Child Guidance Center, “Danielle” has learned techniques in order to prevent re-victimization of sexual abuse. She has also learned the skills necessary to develop healthy relationships with her peers at home and at school.
While CBT is a wonderful treatment modality for trauma resolution, we continue to learn about effective treatments for Traumatic Stress Disorder. All additional traumas are certainly complex as are people’s adaptation to traumatic life experiences. It is hoped that we continue to recognize treatment approaches such as this modality and other approaches that can help integrate traumatic experiences so that survivors see themselves as capable and worthy of healing from the past.