6

The Therapeutic Roller Coaster

Phase-Oriented Treatment for Complex PTSD1

The recognition of the profound effects of early abusive experiences, and the complexity of adult clinical syndromes related to such experiences, underscores the need for a sophisticated understanding of the treatment process for childhood abuse survivors. Because of patients’ many and varied comorbid psychiatric symptoms, clinicians need to understand which problems and symptoms have priority in treatment. Over the past 20 years, a standard of care for complex PTSD has evolved that conceptualizes a sequence of treatment approaches designed to address specific issues in a way that is maximally helpful to patients.2 Several clinician-investigators have advocated using a phase-oriented or stage-oriented approach (Chu, 1992c; Courtois, 1999; Courtois, Ford, & Cloitre, 2009; Herman, 1992b; Lebowitz et al., 1993; Steele, Van der Hart, & Nijenhuis, 2005). All of these treatment models are based on the clinical experience that many survivors of severe childhood abuse require an initial (sometimes lengthy) period of developing fundamental skills, including maintaining supportive relationships, developing self-care strategies, coping with symptomatology, improving functioning, and establishing some basic positive self-identity as a prerequisite for active work on memories of traumatic events.

Much of the earlier literature on the treatment of PTSD focused primarily on the treatment of adult war veterans and others who were traumatized as adults. Some treatment paradigms for this population place a priority on abreaction (see, for example, Foa, Steketee, & Rothbaum, 1989; Frueh, Turner, & Beidell, 1995; Keane, Fairbank, Caddell, & Zimering, 1989). The positive value of abreaction is thought to involve the reexperiencing of the traumatic event in a context of high social support so that the experience is tolerated, attitudinally reframed, and integrated into conscious experience. For example, in the treatment of adults who have been through wartime experiences or similar events, abreaction is sometimes brought about by exposure or flooding techniques whereby the patient is deliberately exposed to stimuli designed to trigger reexperiences of the traumatic events in a supportive and controlled environment (e.g., veterans being shown film clips that simulate combat, individualized trauma scripts based on trauma experiences, computerized virtual reality scenarios). For many veterans with combat-related PTSD, such therapeutic strategies have been effective in alleviating acute symptomatology.

There are no similar studies of the use of abreactive techniques in survivors of extensive childhood trauma. Based on clinical experience, however, it is widely believed that the eventual reexperiencing and working through of childhood trauma is part of the definitive treatment for the resolution of posttraumatic and dissociative symptomatology. Persons who have been able to successfully confront and work through abusive childhood events often experience dramatic changes, reporting that they are able to proceed with their lives unencumbered by their pasts. This abreactive process promotes improvement, such as fewer and less troubling intrusions of the abusive experiences, a reduction in dissociative symptomatology, a new sense of identity as being psychologically healthy and functionally competent, and a much improved ability to relate to the world and to others.

The clear value of abreaction of childhood trauma in some patients led to an unfortunate belief system that is still remarkably ubiquitous among some patients and their therapists. In this belief system, it is assumed that in any clinical situation where childhood abuse is discovered in the patient’s history, all efforts should be made to explore and abreact those abusive experiences. Moreover, some clinicians appear to believe that if current difficulties seem related to past abuse, then abreaction is the treatment of choice. Unfortunately, in the treatment of many patients, such a belief system is conceptually flawed and inappropriate, and can have untoward effects such as increasing acute symptomatology and difficulties with functioning and coping, as illustrated in the following clinical example:

A 22-year-old woman was admitted to our inpatient psychiatric facility after taking an overdose of her antianxiety medication. She had a long history of severe depression, panic, suicidal impulses, poor relationships, and a low level of functioning. She had recently begun treatment with a new outpatient therapist. In the context of therapy, the patient began to reveal evidence of severe early childhood sexual abuse. The patient began divulging more and more information about the abuse, and she became increasingly fearful, isolated, and suicidal. She was referred for hospitalization in order to “work through the abuse issues.” Following her admission, the patient was noted to have flashbacks of presumed childhood sexual abuse. Despite cautions from the hospital staff concerning the need for stabilization as a treatment priority, she and her therapist were insistent on the need to “get the bad feelings out” in order to heal from the abuse. The patient was encouraged by her therapist to explore these issues in therapy, and she related horrific details of repeated victimization, which she reported that she was just remembering. On the unit, her behavior became more and more out of control, particularly at night, necessitating intensive suicide precautions and even the intermittent use of restraints for head banging. After six weeks of hospitalization, she was unable to be discharged and was put on a leave of absence at her job.

The key element that appears to be missing in premature attempts at abreactive therapy in patients with complex PTSD is the ability to utilize social and interpersonal support. Unfortunately, the ability to relate to and feel supported by others is a primary area of disability in many patients with a history of severe childhood abuse. The relational difficulties that complex PTSD patients experience also arise within the therapeutic relationship, often in a particularly intense fashion. The therapist is viewed with great suspicion, and many severely abused patients are unable to take the emotional risk to have a normal level of trust in the relationship. Because therapy involves intimacy, vulnerability, and the potential for arousing painful and overwhelming feelings, the therapist and the therapeutic process are experienced as major stressors and may precipitate negative therapeutic reactions. Characteristically, when faced with any major stressor (internal or external), severely abused patients flee into isolation as the perceived safest alternative, but once again are alone with the burden of their symptoms, feelings of emptiness, despair, and self-hate, and their dysfunctional and self-destructive behaviors.

My clinical experience over three decades with severely traumatized patients with complex PTSD has suggested that the best prognosis has been associated with persons who attempt to gain control of their inner experience and their outside lives, who challenge themselves to overcome obstacles, and who persist in their efforts to attain some semblance of a normal life. In the face of an underlying reservoir of powerful feelings of despair related to their early abuse, these persons struggle to achieve some measure of healthy functioning in the world and in their interpersonal relationships. The initial achievements of these efforts may feel fragile and superficial. However, persistent efforts at functioning result in a sound foundation that consists of a more positive sense of self-identity and self-worth, a sense of control over internal feelings and impulses, an ability to interact with the external environment, a daily structure that provides stability in daily living, and a network of social supports. These accomplishments then may provide some solid ground on which the patient may stand when exploring the quagmires of early abuse. The establishment of this kind of stability is often arduous and lengthy, requiring untold efforts from patients, guidance from skilled clinicians, and endless patience and persistence. There are few shortcuts, and even with competent treatment and maximal effort from both patients and therapists, the early treatment process is often punctuated by crisis and anxiety. It is a common experience for therapists and patients to feel as though they are riding some kind of roller coaster with little sense of control or direction, and to have a constant feeling of impending crisis and potential danger.

Most phase-oriented treatment models consist of three phases or stages:

For example, Herman’s model, described in her much acclaimed 1992 book, Trauma and Recovery, delineated three such phases, rather poetically named Safety, Remembrance and Mourning (the essential processes of coming to terms with momentous past trauma), and Reconnection (in Herman’s conceptualization, the effects of trauma result in disempowerment and disconnection, so healing inherently involves re-empowerment and reconnection). In a somewhat obscure paper published in the same year (Chu, 1992c), I described a treatment model for complex PTSD with three phases that I named (much less poetically) Early, Middle, and Late.

The division of the course of treatment is somewhat arbitrary, because patients generally move back and forth between phases, rather than progressing in a neat linear fashion. However, this delineation is useful in specifying the components and sequence of treatment. The discussion in this volume focuses extensively on the early phase of treatment, as the dilemmas encountered here are the most formidable for patients and clinicians. The middle or abreactive phase of treatment is summarized in this chapter. By the time patients have done the arduous work of the early phase of treatment, they are much more stable, and work on traumatic memories often proceeds in a much more intuitive fashion, largely free from crisis (although it is still very emotionally painful). For more lengthy descriptions of this process, some fine texts discuss in detail the abreactive and integrative process with complex PTSD patients (Courtois, 1999, 2010; Courtois & Ford, 2009; Davies & Frawley, 1994; Gold, 2000; Herman, 1992b) and those with dissociative disorders (Kluft & Fine, 1993; Putnam, 1989; Ross, 1997). The late phase receives the least emphasis here, as it is more familiar to experienced psychotherapists as the work with individuals who are largely functional but who have patterns of thinking, feeling, and behaving that affect the quality of their lives. Three areas that are part of the focus of early treatment—self-care, symptom control, and relational issues—are described in this chapter in brief, as the scope and importance of these areas merit a fuller exploration; they are more extensively discussed in the four subsequent chapters of this volume.

EARLY PHASE TREATMENT

For many childhood abuse survivors with complex PTSD, abreaction and resolution of early traumatic experiences are limited by deficits in being able to tolerate the intense affects and experiences associated with the traumatic events, and their inability to utilize supportive relationships—specifically including the therapeutic relationship. Abreactive work must be deferred pending the development of basic skills concerning relating and coping. In the early phase of treatment, emphasis should be placed on establishing a therapeutic alliance, educating patients about diagnosis and symptoms, and explaining the treatment process. Certain areas of focus can be identified as crucial in the early phases of treatment. These are discussed here as part of the mnemonic SAFER:

Self-Care

Survivors of childhood abuse are prone to become involved in a wide variety of self-destructive and self-harming behaviors (see, for example, Briere & Runtz, 1987; de Yong, 1982; van der Kolk, Perry, & Herman, 1991). Chronic reexperiencing of the affects related to early abuse—including intense dysphoria, panic, helplessness, and hopelessness, as well as a chronic sense of aloneness and disconnectedness—often lead to suicidal impulses and behavior. Self-injury of a nonlethal nature is also extremely common, and paradoxically is often used as a soothing and coping mechanism (Himber, 1994; Shapiro, 1987). Patients with histories of extensive childhood abuse often describe their repetitive cutting, burning, or picking at the skin as tension-relieving rather than painful. Interestingly, this may have an underlying biologic mechanism in the release of endogenous opioids (Kirmayer & Carroll, 1987; van der Kolk et al., 1989).

As described in Chapter 2, survivors of childhood abuse often have other self-destructive and dysfunctional behaviors, such as substance abuse and eating disorders, and also addiction to risk-taking behaviors such as addictive traumatic reexposure (van der Kolk & Greenberg, 1987) or unsafe or risky sexual practices (Koenig & Clark, 2004; Purcell, Malow, Dolezal, & Carbello-Diéguez, 2004). Finally, revictimization is remarkably common, including repetitions of emotional, physical, and sexual abuse (Briere & Runtz, 1987; Chu, 1992b; Cloitre, Tardiff, Marzuk, Leon, & Portera, 1996; Coid et al., 2001; Dutton & Painter, 1981; Follette, Polusny, Bechtle, & Naugle, 1996; Russell, 1986), even within the presumed safety of the therapeutic relationship (Kluft, 1990a).

Childhood abuse survivors tend to be ambivalent about self-care. Perhaps one of the most damaging legacies of chronic childhood abuse is the compulsion to continue the patterns of abuse long after the original perpetrators are no longer actively abusive. In addition, a sense of inner worthlessness may make self-care seem internally consistent or unimportant. And perhaps most significantly, when self-harm is used as a mechanism for self-soothing or affect modulation, alternative coping mechanisms that involve reliance on others may seem extremely risky to the abuse survivors who have backgrounds of abandonment and betrayal. Patients’ propensities toward inadequate self-care through both self-destructive behavior and vulnerability to revictimization must be controlled before beginning any exploratory therapy. Failure to do so increases the likelihood of serious self-harm when traumatic material is broached.

Analogous to the situation of abused children who must be removed from abusive environments as the first priority of treatment, abuse survivors must create an environment of personal safety before they are able to make progress in treatment. To this end, therapists need to insist that the therapy focus on self-care. In the early phase of treatment, this often takes the form of therapists asking for agreement on a therapeutic agenda (e.g., “I know that hurting yourself has been a long-standing coping mechanism for you, and that you may not feel that self-care is important. However, if we are to get anywhere in this therapy, you will have to make a commitment to work very hard to take care of yourself, even when you may not want to.”).

It should be noted that in the early phase of treatment many patients will lack the ego strength to fully achieve self-care. In many situations, lapses will occur, and patients may retreat to self-harming or self-destructive behavior. Such lapses are tolerable if—and only if—patients are able to demonstrate a commitment to the principles of self-care over time and are able to make consistent progress toward reducing dysfunctional behaviors. It is essential to the treatment process that patients ally with their therapists around preventing self-harm, oppose their own self-destructive impulses, and understand the mechanisms of their vulnerability to revictimization. They must also begin to learn how to soothe themselves using alternative and less self-destructive ways of coping with stress.

Symptom Control

Many of the symptoms associated with complex PTSD and dissociative disorders need to be modulated and controlled as part of the stabilization process in the early phase of treatment. Patients are likely to remain in crisis as long as they continue to have frequent reexperiencing symptoms, such as flashbacks, nightmares, intrusive thoughts, feelings, and sensations, along with the accompanying physiologic hyperarousal symptoms of chronic anxiety and disturbed sleep. Hence, limiting the intrusion of traumatic thoughts and feelings during the initial phase of treatment is a crucial part of the therapy of many patients with complex PTSD. In addition, patients with dissociative identity disorder (DID) need to be able to control symptoms such as abrupt state changes (including personality switching) and amnesia; see Chapter 12 for a discussion of interventions more specific to the treatment of DID. Although the goal of early phase treatment is to defer abreaction of traumatic memories to when patients are stable, premature reexperiencing of symptoms frequently and routinely occurs before patients are prepared to process them, contributing to more instability.

In the 1990s, with the shift away from a direct focus on abreacting traumatic events in the early phase of treatment for patients with complex PTSD, the question arose concerning what to do when patients experienced acute posttraumatic and dissociative symptoms. Especially if the symptoms were related to particular experiences (e.g., flashbacks or nightmares of specific events), was it necessary to retrieve memories of the event, or could the focus be just on the symptoms? Over time, on the basis of clinical experience, it became clear that patients could be stabilized without accessing the memories. In fact, any premature exploration of memories often leads to a cascade of more memories, resulting in an unraveling process that is similar to making the mistake of pulling on a loose yarn in a sweater.

The approach can be fairly straightforward. The clinician can certainly listen to what patients have to say about the memories they have recalled; it is almost never appropriate to silence patients or ignore what they are saying. But instead of asking about more details, clinicians can encourage patients to try and manage the symptoms (i.e., stopping further recall and regaining present-day orientation) and provide suggestions on how to do so. On the Trauma and Dissociative Disorders inpatient unit at McLean Hospital, members of the nursing staff have been the most skilled at doing this. Because memories tended to surface in the evening and night (the time of day when many traumas such as sexual abuse occurred), it was not uncommon for a staff member to find a patient huddled in a corner or hiding in a closet having a full-blown flashback. In the early days of the program, staff members rapidly became expert at helping patients focus and reorient to their present circumstances. I and others learned a great deal from their innovative approaches and expertise.

If patients are working in alliance with therapists and other treaters, many behavioral interventions can be effective. Most of these fall into the category of grounding techniques, which help patients to focus on their immediate surroundings in the current reality when they are beginning to be overwhelmed by posttraumatic symptoms. Grounding techniques, if learned and practiced regularly, are effective at increasing voluntary control over such symptoms. Focusing on persons’ immediate environment can help pull out of reexperiencing past trauma. (I recall once receiving a panicked telephone call from a patient who was experiencing a terrifying flashback. I asked her to tell me where she was in her house, and then to go look out the window and to tell me what she saw. With this help, she was able to ground herself in only a few minutes.) Contact with other persons, particularly eye contact, is also enormously effective and conveys two critical therapeutic messages: control of posttraumatic symptoms is possible, and other people can be helpful and safe. Focused activities, familiar objects, and soothing or energizing sensations can be helpful in reorienting patients who are having difficulty with reexperiencing symptoms. Preplanned strategies for achieving control should be formulated for use in managing the crises that can often occur outside of the therapy office at inopportune times. More details concerning strategies and interventions for symptom control are presented in Chapter 8.

Control of intrusive symptomatology can be achieved, but only if patients ally with the goal of attempting to control the rate and nature of reexperiencing past abuse. Therapists must have patience and take the time to provide education and support about how this can be done. In this way, patients can be recruited to ally with the therapeutic process of achieving adequate symptom control. Both patients and therapists should recognize that this process may be quite difficult, and early attempts may be only minimally successful. However, the ultimate goal of the therapy has to do with achieving a sense of mastery over past traumatic experiences, and unless patients are allied with this goal, it will not be attained. Not to strive for control is acceptance of the notion that reexperiencing symptoms are inherently beyond patients’ control and essentially dooms therapeutic efforts.

Acknowledgment

Although intensive exploration of past traumatic experiences may be inadvisable in the early phase of treatment, acknowledgment of the significance of early trauma is crucial. Childhood abuse is perhaps the most important determinant in the lives of trauma survivors, not only in terms of posttraumatic symptomatology, but also in terms of their ability to function in the world and to relate to others. To ignore the role of abusive experiences is to tacitly collude in patients’ denial of the impact of the abuse and in their erroneous beliefs of being responsible for their own victimization. The simple acknowledgment of the possible role of early traumatic experiences begins the process of helping survivors to understand many of their current difficulties as normal adaptive responses to extraordinarily overwhelming events.

Therapists must reiterate that although patients must shoulder the responsibility of the recovery process, they are not responsible for the abuse itself. Therapists often need to repeat variations of the normalizing message: “You are not crazy or bad. You have had normal reactions to very abnormal and traumatic experiences. You could not have stopped the abuse, and you are not responsible for having been hurt.” Somewhat ironically, this message is often poorly received. Patients who are abuse survivors are often remarkably ambivalent about acknowledging the role of trauma in their lives. Although they may be able to understand intellectually the relationship between their early abuse and their current difficulties, on an emotional level they tend to resist acknowledgment of any such linkage.

Patients’ denial concerning the effects of early trauma is both an effort to distance themselves from overwhelming experiences and the very powerful need to maintain a bond with idealized caretakers—even when the caretakers were perpetrators of abuse. Their adaptations to the abusive experiences have formed the core of meaning in their lives (“I was hurt because I was so bad”), and they resist seeing how much their lives have continued to center around flawed assumptions about themselves and others. As a result, it is striking how much many trauma survivors continue to minimize obviously abusive experiences and their effects; for example, one of my patients angrily accused me of being “patronizing” when I used the word “abuse” in describing the pattern of constant denigration and contempt that she experienced as a child. Even bright and perceptive patients—who can acknowledge that no other children could possibly deserve what they experienced—persistently maintain that they were to blame in their personal family situations. Hence, it is not surprising that the corrective messages acknowledging the consequences of early trauma need to be supportively reiterated throughout the early phase of treatment.

Functioning

It is almost impossible to overstate the importance of traumatized patients maintaining an appropriate level of functioning in their lives. Patients who have suffered early abuse are frequently overwhelmed by reexperiencing their trauma. Without persistent efforts on the part of both patients and their therapists to maintain a semblance of normal functioning, these reexperiences can rapidly intrude into every aspect of patients’ lives. A syndrome of recurrent flashbacks precipitating crises, desperate efforts to obtain comfort and reassurance, dysphoric dependence on treaters, and massive regression are seen frequently in treatments that are out of control.

Maintaining functioning is far from a trivial matter. Without some kind of anchor in the current reality, patients can become consumed by the emotional reality of their past abuse. That is, the feelings of victimization, hopelessness, powerlessness, and aloneness are experienced not just as related to the past, but can be overlaid on individuals’ current lives. Over the years on our inpatient unit, we frequently observed patients who were admitted in crisis—and were sometimes intensely suicidal—based on such feelings. They were not able to perceive that their actual current lives were not abusive and well worth living; in short, they lost perspective of the difference between the present and the past. Too often, we saw scenarios in which patients began to psychologically unravel while pursuing premature work concerning past abuse. Many such patients, who may have been marginally compensated in terms of coping, quickly became incapable of functioning at all, and over time they become bereft of any kind of identity other than as a victimized and dependent patient. This kind of result is not only a poor therapeutic outcome but also a major problem that carries considerable risk in terms of increased symptomatology, permanent loss of functioning, chronic depression, and even suicide.

During a crisis, individuals sometimes benefit from the milieu and tasks associated with work. The work setting provides a focus that can distract one from worries and preoccupations associated with painful personal experiences such as loss or conflict, and it can provide balance and perspective in one’s outlook on life. Interaction with others, whether friends or coworkers, is also an antidote to personal distress, providing diversion, support, and a sense of community. Without the demand characteristics of work or other reality-based roles and activities, it is all too easy for traumatized patients to become trapped in the past. Maintaining some appropriate level of functioning is often difficult but is nonetheless essential. Therapists, even those who have been trained to be nondirective in their approach, need to respond with a clear “No” to the often-asked question from patients, “Do you think it might be worthwhile for me to take time off from my usual activities in order to get to the root of my difficulties?” Even if efforts to function seem to patients to be superficial or just going through the motions, they are important in terms of balancing the internal pull toward becoming totally immersed in past trauma.

Another critical therapeutic benefit is derived from functioning. Survivors of childhood abuse routinely have negative self-perceptions, feeling empty, defective, and disenfranchised from others. How does one’s negative sense of self change into something positive? During the course of my formal psychiatric training, I don’t recall ever being taught the mechanisms for such change. But, based on years of experience observing and assisting patients in their recovery, I am convinced that insights achieved in therapy are only the beginning, and the roots of self-esteem and a positive self-image are in actually doing things in life. Summoning up the courage to reach out and connect with others, going to work reliably, following through with an exercise program, and engaging in recreational activities are some examples of types of functioning that begin to instill new positive ways of thinking about oneself to replace the old negative ones (e.g., “friendly,” “productive,” “fit,” “fun-loving”). Over time, healthy functioning in all domains—relational, vocational, educational, and recreational—leads to self-esteem and a positive self-identity.

Therapists must emphasize the importance of maintaining both functioning and supportive relationships, especially in the early phase of treatment. Without this emphasis on functioning outside the therapy, problems such as regression and overly intense transferences are prone to flourish. A sense of mastery in functioning helps reinforce patients’ sense of internal control of their own lives, rather than feeling controlled by their past negative experiences. Paid employment, a volunteer job, regular activities in the home, at school, or in training programs are preferable because they not only provide a positive sense of self but also compel patients to function in the current reality. To the extent to which patients’ activities are not therapy-related, they can provide a balance for the heavy emotional weight of their treatment. However, if patients are unable to meet the challenges of vocational or educational settings, treatment programs such as therapeutic groups, day programs, or AA/NA-related activities are important as areas of functioning.

Expression

The intense affects associated with posttraumatic symptomatology must be expressed in a nondestructive and therapeutic manner. Although full exploration of the traumatic events may not be advisable in the early phase of treatment, patients do experience some of the overwhelming negative affects associated with the trauma, including such intolerable feelings as intense depression and hopelessness, panic and terror, and rage. Particularly because one of the goals of early therapy is to help patients avoid use of ingrained and destructive coping mechanisms, the therapy must help patients find healthier means of expression.

A more subtle difficulty for persons with early childhood abuse has to do with the way that childhood trauma is experienced and recalled. Prior to adolescence, and especially in early childhood, the primary modality of experiencing the world is not verbal, symbolic, and linguistic as it is in adults, but is largely sensorimotor. Traumatic events that occur early in childhood are encoded in the psyche in a modality that is primarily nonverbal. Neurologic studies of the effects of child abuse on brain function suggest that trauma results in overactivation of right brain (nonverbal) activity as compared with left brain (verbal) activity (Schiffer, Teicher, & Papanicolaou, 1995). Thus, when traumatic events are relived in current reality, they retain a strikingly nonverbal quality. In the clinical arena it is quite striking to encounter patients who are otherwise highly intelligent, verbal, and articulate, but who literally seem to have no words to describe their childhood experiences. For these patients, their experiences of early childhood abuse remain both literally and figuratively unspeakable.

The inability to find words to describe feelings and events concerning early abuse has important implications. Achieving a sense of control over internal mental processes depends on the verbal ability to organize and contain powerful emotional processes. For example, the verbal thought, “I am afraid because I feel as though everyone will hate me like my mother did” is much more manageable than nameless dread. Not only can the feeling be named and described, but it can be consciously countered with other verbal narratives, such as “My mother was a unhappy and tortured person who hated everyone, and other people have no reason to hate me.” Thus, the difficulties that traumatized patients have in being able to verbalize their experiences leave them more vulnerable to being repeatedly overwhelmed. This inability to verbalize experience also results in patients being unable to communicate with and to receive support from others. It is a common experience for patients to be flooded by powerful but wordless feelings and memories, but to feel intensely alone even in the presence of a therapist or other supportive persons. Finally, intense nonverbal experiences often leave little alternative to traumatized patients other than acting out. Because the underlying basis of this kind of acting out cannot be communicated and may involve avoidance, flight, or even self-destructive acts, such behavior is often poorly understood and sometimes characterized as deliberate misbehavior. However, true acting out is an expression of intense underlying affects without conscious awareness of them, not just another undesirable and difficult patient behavior. Acting out is also an opportunity for the patient and therapist to begin to search for words to describe the patient’s chaotic and inarticulate internal world.

Unspeakable feelings need to find expression in words. However, in the early phases of treatment, verbalization of very intense feelings may be a difficult task. This process may be facilitated through therapeutic nonverbal expression, and the expressive therapies may have a special role in encouraging and working with trauma patients. After all, the expressive therapies are specifically designed to help patients translate nonverbal feelings into words. It is a common experience for abuse survivors, who are unable to speak about their feelings, to be able to find some relief through art, music, or physical activity (movement, dance, exercise, or sports). Even writing is sometimes nonverbal; certain patients describe sitting with a pen and paper and allowing words to flow out onto the paper without conscious awareness of their content. In the early phase of therapy, such efforts should be directed primarily at therapeutic expression (e.g., venting tension) rather than exploration of traumatic events and can be powerful forces in helping patients to find words for their previously unspeakable feelings.

Formal expressive therapy is best left to trained and qualified expressive therapists. However, even verbal psychotherapists can help patients find nonverbal channels for explosive feelings. Therapists can support patients in pursuing expressive activities or can even simply encourage a program of regular physical activity. The latter modality can be a very effective outlet for a variety of dysphoric affects. After all, intense panic or rage is a visceral experience that is normally felt more in the body than in the mind and is not easily verbally expressed even among those who have not been traumatized. Training in relaxation techniques, guided imagery, or autohypnosis (self-induced trance states) can be useful to combat both dysphoric feelings and the bodily overactivation that occurs in posttraumatic conditions. However, early in treatment, it is important that any such efforts be directed at containment of feelings, especially anxiety, and not at exploration of traumatic events.

Relationships

Negotiating relational minefields with survivors of early abuse is undoubtedly the most challenging aspect of the therapeutic work and is usually the rate-limiting aspect of the treatment. Survivors of childhood trauma bring the abuse-related interpersonal assumptions of their childhood environments into all of their adult relationships, including the therapeutic relationship. These relational assumptions often transform the therapeutic relationship into an emotional battlefield in which the patient and therapist take on abuse-related roles. Through complex interactions including projective identification, the patient and therapist end up playing out these various roles, making collaborative work on resolving past traumatic experiences extremely difficult. The most important task of early phase treatment is beginning to replace the model of abuse-related relationships with patterns of interpersonal interactions that are mutual and collaborative.

In the early phase of therapy, the patient and therapist must repeatedly renegotiate the therapeutic alliance. As the patient is repeatedly unconsciously compelled to precipitate abusive reenactments that disrupt the treatment relationship, the therapist must empathically interpret the process and help the patient in developing a sense of collaboration and mutuality. This process of disconnection and reconnection must occur on seemingly endless occasions with endless variations before a minimal sense of basic trust is formed. The following clinical example is a rather dramatic illustration of this process:

I once supervised a doctoral student in her psychotherapy of several patients with histories of early trauma. The student had already had extensive experience as a master’s-level therapist, but she was finding one of her patients—Ruth, a 34-year-old woman with a history of severe childhood abuse—particularly difficult to treat. My supervisee was confident enough to bring actual audiotaped recordings of therapy sessions to our meetings, which lent a striking note of reality to my experience of the therapy. There had been some blurring of the therapeutic boundaries as the patient anxiously sought reassurance, and because the frantic calls had become numerous (almost daily) and intrusive, the therapy had been focused on reestablishing the treatment frame. Ruth was quite unhappy (understandably) about limits being placed on the out-of-the-office contacts and complained angrily that she was being treated unfairly and that her therapist was cold and uncaring. In very angry and accusatory tones she said, “I’ve seen many other therapists, but when I met you I thought you were the first person I could really trust—and now you betray me. I can’t believe you’re doing this to me. You don’t care about me and just want to get rid of me. You’re just like everyone else! No, in fact you’re worse because you pretend that you care.”

The therapist was initially taken aback by the vehemence of the verbal barrage, and feeling defensive and unfairly attacked, had difficulty even finding words to respond to the patient (a common reaction even for very experienced therapists). However, after a number of fruitless interchanges, she finally was able to say, “I’m sorry you feel so hurt. It is not my intent to abandon you. In fact, I am just trying to work out this relationship so that I can continue to help you over the long haul. I realize that I may have been somewhat unilateral in talking about my limits, and I would be very interested in your ideas about how we might solve the problem of phone calls, as it’s very important we find ways to work together.” Ruth almost instantly became calmer and replied, “You’re really interested my ideas? I didn’t know you cared about how I felt. You have to remember that in my family you could literally scream all you wanted and nobody heard or cared.” In this way, mutuality was reestablished. However, the vicissitudes of the interpersonal process soon continued, as the patient said, “But I still can’t believe how you talked to me as though I was just a bother to you.”

This is the therapeutic dance, a seemingly endless cycle of disconnection and reconnection that occurs repeatedly, sometimes in the course of even a single therapy session, and certainly over the weeks, months, and sometimes years in the early phase of treatment. This process makes this phase of therapy long and arduous, but this process also provides a new model of relatedness that is in sharp contrast to the abusive style of relatedness the patient has experienced and expects. The therapy helps the patient to actually experience mutuality and collaboration in the relationship, rather than the control, aggression, exploitation, abandonment, and betrayal that formed the core experiences of the patient’s early life. Establishing and providing this alternative interpersonal process is the core of the so-called corrective emotional experience. That is, the reparative process is providing patients with a new experience of a relational model with which to obtain support, to resolve conflict, and to feel a powerful sense of connection with others. The corrective emotional experience is not about taking care of patients. Although most therapists are compassionate and do a certain amount of caretaking of their patients, this alone does not bring lasting change in the patient’s basic relational assumptions.

Therapists who expect patients to respond positively to an approach that consists primarily of caretaking or reassurance will be ill-equipped to weather the vicissitudes of the therapeutic process with abuse survivors. Patients who have been damaged by early interpersonal trauma cannot be “loved into health.” Therapists must learn the hard lesson that the process of therapy with severely traumatized patients is rarely straightforward. It is not easy for therapists to understand and accept that they will not be able to consistently relieve patients’ suffering, avoid conflict, or be seen as positive and helpful. In fact, to the extent that the therapy sometimes does provide help and relief, it can be all the more frustrating to patients and therapists that such experiences occur only intermittently.

Despite therapists’ efforts to be helpful and benign, they will not always be regarded as such. Therapists must recognize that no matter how kind and compassionate, tolerant, or skilled they may be, they will likely find themselves as the objects of “traumatic transferences” (Spiegel & Spiegel, 1978), being regarded as abusers, and the object of patients’ anger, suspicion, and even sadism. They must also be prepared to feel themselves being pulled into the position of feeling enmeshed, helpless, and violated, which are repetitions and reenactments of the experience of the abused child. Many, if not all, of these experiences in the therapeutic relationship are an integral part of working with patients who have had horrific life experiences, and they should be viewed as opportunities for work and change. Therapists must be prepared to work with such situations and to deal with their own countertransferential feelings. Using the framework of the “therapeutic dance” to understand the cycles of the therapeutic relationship can assist therapists to help advance the process and to formulate strategies to move the relationship toward a more psychologically healthy and stable collaborative position.

Patients vary widely in ego capacity, motivation, social support, economic resources, and other factors that may make them more or less able to use treatment to make fundamental changes. Accordingly, some patients may need to continue in early phase treatment for years—and sometimes even for the entire course of treatment. Such patients are often able to improve considerably in terms of overall stabilization and functioning, but they may not have the internal resources to engage in an intense (and potentially destabilizing) exploration of their trauma memories. Many factors may contribute to chronic low functioning, including severe attachment problems, ongoing enmeshment with perpetrators, serious and unstable comorbid conditions, ongoing medical problems, and unremitting life stresses, among others.

MIDDLE PHASE TREATMENT

In the middle phase of treatment, the focus turns to working with the patient’s memories of traumatic experiences. Effective work in this phase involves remembering, tolerating, processing, and integrating overwhelming past events. This work includes the process of abreaction—the release of strong emotions related to an unresolved past experience. Herman (1992b) speaks of abreaction as the reconstruction of a comprehensive verbal narrative of such unresolved traumatic events, where “the therapist plays the role of witness and ally, in whose presence the survivor can speak the unspeakable” (p. 175). When traumatized patients have mastered the tasks of the early phase of therapy, they may then cautiously proceed to the exploration and abreactive work of the middle phase of treatment. Patients vary considerably concerning the pace of treatment. Some enter therapy with excellent coping skills and may quickly move toward middle phase treatment. However, as noted in the previous section, many others require months or years of preliminary work.

Abreactive work should always be undertaken from a position of strength rather than vulnerability. Without adequate preparation and support, patients are prone to reexperience traumatic events once again in isolation and to be repetitively overwhelmed by them. In treating hospitalized patients over many years, the precipitating factors for decompensation have sometimes involved unstable patients undertaking a torturous process of going through a long series of out-of-control abreactions, with therapists making sometimes heroic efforts to help contain these explosive events. Although abuse survivors may be able to vent affect and release internal tension through uncontrolled abreactions, these experiences have resulted in very little lasting therapeutic value. Effective abreaction involves emotional processing, cognitive change, and achieving a sense of mastery concerning the trauma in addition to the intense discharge of emotions related to the traumatic experiences. If the only process is emotional discharge, it is simply retraumatizing, and thus is contraindicated.

Abreactive work should not involve crisis. Achieving full understanding and integrating past traumatic experience certainly involves confronting very painful feelings about past realities, but it should not result in patients feeling so overwhelmed that a crisis is precipitated. For the most part, effective abreactive work takes place in an outpatient office setting. Many patients enter into therapy with the expectation of resolution of traumatic issues through a kind of cataclysmic catharsis. Although there may be breakthroughs of understanding and instances of intense emotional release, working through trauma should be a somewhat modulated and progressive process that is accomplished over time. As early abreactive work is successfully completed, patients draw strength from new understandings about their lives and feel progressively freed from conflict, intrusive memories, and self-hate. This new strength is then an asset that allows them to go on to achieve resolution of other conflictual areas, or even to return and rework other aspects of areas already broached. Clinical experience suggests that working through each major issue or important event may entail a prolonged process lasting days, weeks, or months. The process must often be repeated until all major issues or events are resolved. However, it is not necessary to process every single traumatic event in the patient’s past; this would be almost endless given the chronic victimization in the histories of some patients. Rather, only key traumatic experiences need to be processed in order to give new meaning and perspective to similar experiences.

Significant regression is commonly observed in the face of abreaction of traumatic experiences. That is, under the stress of reexperiencing early abuse, patients may return to former patterns of isolation and dysfunctional or self-destructive behavior. If and when these patterns reemerge, clinical attention should return to early phase issues until these issues are once again mastered. In fact, it is precisely because of the inevitable regressive pull of abreactive work that early phase issues must be mastered. Patients need to establish powerful relational bonds and be prepared to withstand extremely dysphoric affects without resorting to dysfunctional behavior in order to tolerate abreactive work. Plus, they need to have begun the work of establishing a more positive sense of themselves and their lives in order to be able to distinguish the present reality from the feelings related to the past.

Clinicians should provide education about the nature of the abreactive process, including the likelihood that symptoms may be exacerbated, as well as the benefits of successful memory processing. Work on traumatic memories can sometimes be planned out and scheduled. The patient and therapist can discuss and reach an agreement upon which memories will be explored, what interventions might be employed, how much of the memories can be accessed in any given session, how to titrate the emotional reactions, and how to contain the memories if the process becomes overly intense. There are many ways to access and work with memories. My preference (based on very traditional training) is to allow the memories to surface naturalistically, and then simply to gently explore their content and the associated feelings and meanings, how to understand them, and what the events have meant in the patient’s life. However, some specialized modalities have been used to facilitate the abreaction, such as hypnotic interventions to access and process memories (e.g., Brown & Fromm, 1986; Spiegel, 1988), EMDR (Shapiro, 2001), and specialized techniques to help control and modulate the intensity of the abreactive experience, for example, visualizing the traumatic experience on a screen with controls for the speed and volume (Spiegel, 1988). These specialized modalities should be used only with appropriate training and as needed to facilitate therapeutic processes.

Although patterns of abreaction differ according to the individual characteristics of patients, I have observed several common phases. These are (1) increased symptomatology, particularly more intrusive reexperiencing, resulting in (2) intense internal conflict, followed by (3) acceptance and mourning, which is transformed into (4) mobilization and empowerment. An increase in the reexperiencing of traumatic events is a common early feature of the abreactive process. Again, I should emphasize that this reexperiencing should occur without a major breakdown of functioning. The patient should have the ability to maintain grounding in current reality throughout the abreactive process. Acute reexperiencing may take many forms. Major traumatic events may be reexperienced with symptoms such as nightmares and disturbed sleep, increased anxiety, dissociative experiences, and generalized autonomic hyperarousal. Other kinds of reexperiences may be more subtle. For example, the past experience of being subjected to pervasive hatred and denigration may be reexperienced as intense feelings of shame, self-hate, helplessness, aloneness, and despair.

Paradoxically the initial reexperiencing symptoms are sometimes accompanied by the patient’s efforts to deny any link to traumatic events or to even use dysfunctional defenses (e.g., isolation), but the denial and defenses begin to break down as patients are able to utilize the support of the therapist and others in their lives. With the help of this kind of support and utilizing newfound coping skills, patients begin to tolerate the reality of past events, including the associated overwhelming affect and bodily sensations. They find words to describe the memories, translating the experience into a verbal narrative. The function of the therapist is to witness, support, and empathize, to reframe perceptions and meaning, and to help with pacing and containment. The reframing of the traumatic experiences is a crucial step, and being able to remain connected with others is crucial in this process. These connections enable the patient to utilize the perspectives of others—perspectives that often cannot be gained by the patient alone. In fact, it is sometimes useful to encourage patients not to try and work out painful issues on their own between sessions, especially when they find themselves going over the issues repetitively without being able to resolve them. With appropriate outside perspectives, the events that were originally experienced from the perspective of a helpless abused child can be seen from a more adult viewpoint, and patients can understand them in a different way (e.g., that they were victimized and exploited because of the failings of their abusers, not because they were deserving of such treatment).

New perspectives about past abuse produce intense internal conflict. For example, patients are often unable to let go of long-held feelings of self-blame at the same time that they begin to understand that they were not responsible for their abuse. Patients may retain a sense of identification with the perpetrators of abuse or may still feel intensely protective of them, even though they realize that they were victimized by them. Abuse survivors may also experience intense shame about not having been strong enough to stop the abuse, or having “given in” to the abuse, even though they understand that they were helpless in the abusive situation. In the face of markedly different ways of thinking about internal beliefs and attitudes about the abuse, it is almost universal for patients to try to reject old ways of thinking (e.g., those related to helplessness, powerlessness, and guilt). However, this rarely works, and patients often end up feeling tormented and conflicted. The resolution of such conflicts involves the patient’s new, stronger, and healthier aspects of themselves coming to understand and developing compassion for the old and dysfunctional aspects. That is, patients must understand that some intrinsic aspects of themselves—including unpleasant feelings, thoughts, behaviors, and identities—were molded in very painful ways by extreme events, and that these self-identities need to be accepted and nurtured rather than hated and rejected. Acceptance and integration of past feelings and behaviors, as opposed to rejection and disavowal, leads to the resolution of these internal conflicts.

Persons with dissociated and unresolved abusive experiences frequently underestimate and minimize the extent of their own victimization as a way of protecting themselves from the full impact of the abuse. Despite the intense dysphoria that often accompanies fragmentary memories of the abuse, survivors are often stunned when they fully realize the extent and meaning of past abuse. One severely traumatized patient was finally able to give some eloquence to her experience after years of treatment:

I have been struggling for years to “get it.” I’ve realized for some time now that I’m smart, but I still couldn’t understand it. I went all around in circles rather than just realizing what had really happened. I now know why I couldn’t understand it. To accept what happened takes away the whole meaning of my childhood. I had to believe I was hurt and hated because I was so bad, and so all these years I hurt and hated myself. And I was so alone with my self-hate—no wonder I tried to kill myself. It’s so unbelievable that they could have done that to me if I didn’t deserve it. It makes everything seem so pointless—nobody really benefited. It didn’t have to be that way—but it I guess I have to accept that it was that way.

As patients begin to accept the reality of their past abuse, they are often overcome by the extent of their former helplessness and by the abandonment and betrayal of important people in their lives. This part of the abreactive process often leaves patients emotionally drained, analogous to survivors of a natural disaster who are just beginning to take in the extent of the devastation that has destroyed their lives.

Full realization of the extent of their abuse, and the subsequent toll it has taken on their lives, allows patients to begin to mourn the losses that have resulted from the abuse—those things that they missed and those that couldn’t happen as a result of their victimization. This slow and painful process may involve patients examining each significant aspect of their pasts and reframing their understanding of the events and their meaning. Patients begin to accept that they were truly not to blame for their victimization and to understand how the early abusive experiences pervasively influenced the course of their lives. Supported by these insights, patients begin the process of surrendering the role of victim and replacing it with a sense of self as a survivor of abuse. Over time, the abreactive process enables abuse survivors to mobilize their strengths and to gain a sense of control over their lives. Another patient once remarked to me:

I once read a story about a man who had been a political prisoner. For years he was kept in a cell that was five feet wide and nine feet long, separated from anyone else. His routine was the same each day—he got up at 6:00 each morning, ate twice a day, and was allowed to bathe once a week. The rest of the time, he spent walking up and down the nine feet of his cell, back and forth, back and forth. As an old man, after almost 30 years, he was released and went to live with relatives. For the rest of his life, he got up at 6:00 each day, ate twice a day, bathed once a week, and spent his time walking back and forth in his bedroom—up nine feet and back nine feet. I realize that’s what I’ve done most of my life—living in captivity although I’m no longer a captive. I now know I don’t have to stay in my cell. My life has been ruled by fear, but I finally feel as though I can escape and be free.

Pervasive distress becomes more focused as nameless feelings become understood and can be verbalized in words. For example, rather than experiencing wordless automatic terror and numbness in close proximity to all men, sexual abuse survivors may be able to recognize that specific men were responsible for the abuse and to verbalize, “These men are not the men that hurt me and are not looking for ways to destroy me.” They may then be able to focus their fear, anger, and outrage at the perpetrators as opposed to a more generalized displacement of these feelings.

Abreaction of past trauma frees traumatized patients from fear of their own dissociated memories. Their nightmarish childhood realities lose the power to overwhelm and control them—huge and malevolent abusers are seen as smaller and less powerful, and even horrific events become part of the past rather than repetitively intruding into the present. A remarkable transformation slowly occurs, as the sense of self is enhanced by an understanding that they have been able to tolerate and overcome their past abuse. Having understood and overcome extraordinary past circumstances, abuse survivors can find a new sense of empowerment, including the sense that they can protect themselves from future victimization. Having been able to acknowledge their own victimization and to come to terms with the realities of human failings such as selfishness, aggression, and malevolence, abuse survivors often begin to take on a depth of character in terms of self-understanding and true empathy toward others. After her long and continuing struggles to overcome the effects of abuse, one of my patients reported:

You asked me months ago if I would like to trade places with someone else—someone that I admire. A few years ago I would have said “Yes!” in a minute, but now I don’t think so. This is my life, and even though I wish sometimes it wasn’t, it has made me who I am and I don’t want to be someone else. I’ve had to look at myself and examine myself and learn how to accept myself, which has been incredibly painful. I know a lot more about myself and about others than most people—probably as a result of what I have been through. I like myself, and I really think that I’m okay. I’ve been told that adversity breeds character and I suppose it’s true, but I can’t help from thinking that I would have settled for a little less adversity and a little less character.

Gaining this kind of perspective through integrating past traumatic memories into normal experiences and existing mental schemas permits the memories to be understood and accessible to ordinary recall. After all, the therapeutic work with traumatized patients is not about trauma per se or abreaction as the goal of treatment—such a focus only leads to an endless parade of traumatic experiences and endless abreactive processes. Abreaction is the means through which survivors of trauma begin to build a credible, personal narrative that helps them truly understand how they have become who they are, why they feel what they feel, why they do what they do, and how they can go on with their lives.

LATE PHASE TREATMENT

Much of the process of late phase treatment is similar to that of nontraumatized patients who may have entered therapy functioning well, but experiencing emotional, social, or vocational problems. The abreaction and resolution of past abusive experiences enables trauma survivors to proceed with their lives relatively unencumbered by their pasts. Late phase therapy involves consolidation of gains, achieving a more solid and stable sense of self, and increasing skills in creating healthy interactions with the external world. The resolution of the all-encompassing and overwhelming past events reduces patients’ inevitable narcissistic preoccupation with their symptoms and difficulties, and allows them to have more appreciation of others as separate individuals. Moreover, an empowered sense of self leads patients to have increased confidence in their abilities to participate successfully in interpersonal relationships and other activities in ways that previously eluded them. In persons with a fragmented sense of identity, a profound sense of an integrated self arising from new psychic structures often emerges, which facilitates their ability to engage with the external world.

It is common for patients in the late phase of therapy to find areas of unresolved trauma or trauma-related issues as they proceed with their lives and encounter new situations. This process should be construed only as a need to complete further abreactive work and not as a failure of therapy. In fact, it is sometimes necessary for patients to revisit traumatic memories that had previously been processed from a more adult and integrated perspective. The history of successful experiences with abreactive therapy often facilitates and often shortens any additional similar subsequent treatment.

A final quote from another patient illustrates the new perspective of those who have been able to rebuild their shattered lives:

When I look back, it’s incredible I ever made it this far. How many times did I feel I couldn’t get any further? How many times did I try to kill myself? I think if I knew in the beginning what it would take to get to this point I never would have tried. There were so many years spent just getting through, and then so many years undoing what was done to me—so many years just getting to the point that I could have a chance just like anyone else. In a way, it’s so unfair that I have had that job of “undoing.” I’ve had to struggle and struggle to do what seems so easy for everyone else. But, I guess I’ve learned that no one else could do it for me, although God knows I’ve needed a lot of help. Life isn’t always easy for me now, but I don’t expect that. I feel lucky and very thankful for having the chance to do all the things I’ve done and to have a real future. It’s scary to admit this, but I’m looking forward to the rest of my life.

1 Portions of this chapter were adapted from the article “The Therapeutic Roller Coaster: Dilemmas in the Treatment of Childhood Abuse Survivors” (Chu, 1992c).

2 Although this has been a new approach in the modern study of trauma treatment, as early as the late 19th century, Pierre Janet advocated a phase-oriented treatment for dissociative disorders (see Van der Hart, Brown, & van der Kolk, 1989).