Adult Survivors of Sexual Abuse in Couple and Family Therapy
Name of Family Form
Childhood sexual abuse often impacts adult romantic relationships. Adults who have been sexually violated as children often carry wounds that are triggered in current relationships which carry similar dynamics to the relationships in which the sexual abuse occurred. Interactional cycles of survival are then activated in the couple relationship which make it difficult for survivors and their partners to feel in control, powerful, and connected. Sometimes, intimate adult relationships retraumatize adult survivors. Therapists who are not trauma informed may unwittingly do the same thing. This chapter will introduce clinicians to the Collaborative Change Model (CCM), a trauma-informed model of couple therapy, which helps couples where one or both partners are survivors.
The Collaborative Change Model was first introduced by Trepper and Barrett (1986) to treat incest in a family context. In the last 30 years, the model has been practiced worldwide in a variety of settings and for work with individuals, couples, and families coping with trauma. In its current version, the CCM (Barrett and Stone Fish 2014) is a clinically evaluated model that helps practitioners collaborate with other professionals, and the individuals and families they are involved with, to move from survival mindstates to engaged mindstates. The model is a blueprint for helping professionals engage with each other and their clients. There are three stages to the model. The first stage, Creating a Context for Change, is based on the knowledge that healing begins to occur when people experience safety. The second stage, Challenging Patterns and Expanding Alternatives, is the practice of new behavior that leads away from survival mindstates to engaged mindstates. Individuals acting from engaged mindstates have access to and incorporate tools that regulate their affect, cognitions, behaviors, and relationships. The third stage, Consolidation, integrates new learnings and provides hope.
The CCM was developed from many years of working with families whose members had experienced complex trauma. Complex trauma is a pervasive mindset that develops from historical and ongoing abusive and violating relationships and contexts. Many clients who have a history of complex trauma come to therapy stuck in survival mindstates and want help managing their lives. Clients with complex trauma often begin the treatment process having been traumatized in relationships that have similar characteristics to the ones they are entering into when they seek help. Clinicians, on the other hand, come to the relationship with the explicit understanding that they are to be helpful. In most psychotherapy training, trainees are taught to begin therapy after a brief period of “joining,” move quickly into assessment, followed soon after by interventions to challenge unproductive behaviors, thoughts, and feelings. Unfortunately, this rapid movement toward challenge and change can and often does trigger a survival mindstate for clients who have experienced complex trauma.
Developing a new relationship with a helping professional is stressful as is the change process. It can be disorienting and threatening. Clients often experience therapy as something that is happening to them. They have no idea what to expect and do not understand the rules. Lacking a detailed blueprint for the process of therapy the therapist’s actions may seem confusing, irrelevant, or critical. This stressful situation triggers survival mindstates in which it is virtually impossible to achieve therapeutic growth. All of the clients’ energies are focused on surviving while in this state and change is not an option. Therapeutic interventions are neutralized and become ineffective at best and re-traumatizing at worst. The essence of a trauma-informed model is the active and transparent use of collaboration. Clients are active members of the treatment team, and are informed consumers throughout treatment.
The CCM follows a clear sequence of stages and is at the same time flexible and adaptive to therapist style, theoretical model, clinical setting, and client presenting challenge. Helping others grow and change is a creative and sacred process. The CCM allows each and every client and therapist together to design the creative process of change that fits their strengths and styles. Trauma-centered interventions are incorporated into the blueprint of the CCM in conversation with the needs of clients.
Relevant Research About Family Life
It is difficult to accurately estimate the number of adult survivors of childhood sexual abuse who come for couple therapy. If therapists do not take a detailed history, clients may not report past abuse. Even if therapists ask, individuals may not report, for a variety of reasons. They may not have shared their history with their partner, they may not have acknowledged their abuse to themselves, they may experience shame that silences them, they may not trust therapy, or believe it is relevant to their current problems.
It is also difficult to accurately estimate how many people are adult survivors of childhood sexual abuse because researchers differ on definition and most believe that sexual abuse itself is underreported (e.g., Briere and Elliott 2003). Studies done by the Crimes Against Children Research Center show that 1 in 5 girls and 1 in 20 boys are victims and self-report studies show that about 20% of adult females and 5–10% of adult males recall at least one incident of childhood sexual abuse (Finklehor 2008). Children who have been sexually abused are more likely to be sexually abused again as adolescents and adults (Russell 1986; Messman-Moore and Long 2003).
Since Russell’s (1986) landmark study on incest and Herman’s (1992) groundbreaking book comparing the epidemic of childhood sexual abuse to other forms of trauma, many researchers have studied the effects of sexual abuse while acknowledging that research is limited by the secrecy surrounding abuse, particularly when it is intrafamilial. Reactions to abuse vary widely and there is no single profile that defines specific symptomology related to childhood sexual abuse. There are, however, some common individual and relational themes.
At least two decades of reviews of research (e.g., Briere and Elliott 2003) have shown many survivors of childhood sexual abuse suffer low self-esteem and symptoms of anxiety and depression. Some suffer from posttraumatic stress disorder, alcohol and drug abuse, self-mutilation, borderline and bipolar personality disorders, suicidal ideation, aggression, and sexual acting out and dysfunction. Furthermore, adult survivors of childhood sexual abuse are more likely to suffer from medical problems than the general population.
Childhood sexual abuse also has consequences on adult intimate relationships. Sexual difficulties, from pain to avoidance, to low desire, and risky sexual acting out, have an impact on the survivor and her/his partner. There is also some research, which suggests that severe abuse is correlated with more sexual difficulties (Trickett et al. 2011). Valliancourt-Morel et al. (2016) found that relationship status may impact sexual difficulties, discovering that adult survivors in marital relationships were more likely to avoid sex while single survivors were more likely to act out sexually. Research shows that other symptoms related to childhood sexual abuse also have an impact on intimate relationships, like attachment disorders, affect regulation, a sense of powerlessness, and lack of trust. Some survivors, however, do not experience symptomatology related to the abuse when studied as adults. Collishaw et al. (2007) attribute the survivors’ well-being to their relationships with their parents, adolescent friendships, individual personality characteristics of the survivor, and the quality of their adult relationships.
Special Considerations for Couple and Family Therapy
When working with adult survivors of childhood sexual abuse, a trauma-informed lens is invaluable. It appears that most trauma-informed models of couple therapy highlight the importance of safety when working with adult survivors (e.g., Courtois and Ford 2009). This is particularly important when working in conjoint sessions since couples trigger each other into interactional cycles of survival that create dangerous emotional territory and have the potential to explode in the therapy room. In stage one of the Collaborative Change Model (CCM), therapists overtly discuss ways to make the therapeutic environment as safe as possible. They talk with clients about what feels safe and what does not and help couples explore the idiosyncratic ways that they can maintain safety in therapy.
In the first few sessions with couples, concepts from neuroscience are introduced that are helpful in understanding how traumatic experiences in childhood continue to impact them today. Often the explanation goes something like this: “So we are learning a lot about the brain recently that I find helpful in understanding why we do the things we do and how to change our behavior to cope better. So the three parts of the brain the cortex, the limbic area, and the survival brain all have different functions. The cortex, that part of our brain that pays attention, learns, is thoughtful, processes information, helps us with impulse control, etc., is the part of the brain we want to keep on line all the time in therapy. We will explore ways to do that as part of the therapy process. The limbic area is the expression and mediation of emotions and feelings, including emotions linked to connection with others. It also includes the amygdala, which is our danger signal. Sometimes, when we have had a lot of trauma in our past, the danger signal can be over- or underactive and that is something else we will explore as we work together. The survival brain is the oldest part of the brain and has kept us alive since the beginning of time. It is instinctual and unconscious and reacts to danger by taking action to keep us safe.
Fight, flight, freeze, and tend and befriend are the four survival options we have when our survival brain is activated. Adrenalin and cortisol are released, our pupils dilate, our breathing and heart rate go up and we are pumped. We defend ourselves by fighting or running away as fast as we can or taking cover and protecting others or protecting ourselves through eliciting support from safe people. If these three options are not available to us, we can’t fight, we can’t get away, and there is no safe person to tend to us, if we are completely helpless and out of control, the body has a way of shutting down and protecting itself. This is the frozen or dissociated state, almost like we have left the room, or some people talk about being out of body or seeing themselves from afar. The survival brain often kept us alive as children and overfunctions now when it is not necessarily always needed. We will explore many of the incidences that occur in your current life that trigger your survival brain.”
The CCM is a stage model that works like a fractal. The first stage, creating a context for change, which includes a plan for titrating safety and challenge, is repeated continuously, moment to moment and session after session. When working with adult survivors of childhood sexual abuse in couple therapy, this is an essential part of treatment protocol. Many sexual abuse survivors were perpetrated in relationships with adults who were supposed to protect and care for them. Some of the ways therapists attempt to show curiosity and empathy may trigger clients who were groomed and abused by adults who used similar techniques. When the survival brain is triggered, the CCM trained therapist helps clients pause and ponder the trigger, which activates the cortex and helps to create safety in the therapeutic relationship.
Interactional Cycles of Survival
An example of an interactional cycle of survival goes something like this. Often when Theresa’s survival brain is triggered, she becomes convinced that Mattis, her partner of 12 years, is not trustworthy. Theresa was sexually abused by a stepfather who lied constantly, telling her he felt awful about his drunken behavior and would stop the sexual violence, only to repeat it the next time he drank. When Mattis, for example, forgets to call Theresa and let her know he is meeting a friend for a drink, Theresa’s survival brain is triggered. She becomes anxious and mistrusting and convinced he is hiding something from her. She obsessively checks phone records, credit card statements, social media, and follows him to work, and weepily question everything he says. This behavior triggers Mattis’s survival brain. Feeling like a cheating loose when he believes he has done nothing but be forgetful, reminds him of growing up with a mother who would periodically, for no reason that Mattis could understand, trash his bedroom looking for drugs or weapons or sexual paraphernalia that did not exist. He reacts to Theresa’s behavior by shutting down, stonewalling, leaving the house, which of course, triggers Theresa’s survival behavior.
Once the interactional cycle is mapped in stage one of the CCM, the pattern is challenged in stage two. Therapists use various techniques to help explore how partner’s behavior triggers survival behavior. The survival behavior may have been valuable in the past, and that is sometimes explored, but now gets in the way of increased intimacy, feeling valued, connected, and in control. Exploring how the survival behavior made sense in the context of the traumatic abuse of childhood in the presence of an engaged, compassionate partner, helps heal the wounds of the traumatic event. So when Theresa, for example, talked about her stepfather’s abuse and how powerless she was as a teenager, in front of Mattis, as the therapist guided Mattis to witness without taking on Theresa’s anger or trying to fix Theresa’s hurt feelings, he is actually helping Theresa heal. Furthermore, Mattis is calming his own nervous system down as well, a skill he can generalize outside the therapeutic encounter.
New interactional cycles are then practiced. These new patterns incorporate all parts of the brain and are practiced with intension. When they are triggered, they can recognize their reactions from an engaged mindstate, and make decisions about how they want to behave. In stage three, both partners have incorporated ways to support each other when one is triggered, preventing interactional cycles of survival, and providing each other a safe haven to cope with life’s ongoing demands.
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