Friday, August 25, 2006

Post Traumatic Stress In Adult Survivors Of Child Abuse

Trauma specialists believe that "what is most tragic about child abuse and neglect is the exploitation of the child's attachment to the parent." To be sure, it is far easier to abuse one's own children, precisely because their love and loyalty to the parent render them much more compliant than they would be to a stranger. It is exactly this attachment exploitation that teaches children they are not safe in a relationship to other human beings.

Physical abuse itself does not cause trouble. Most people have had physical injuries, fractures or burns during childhood due to purely accidental causes and they have not been harmed by it because they have been comforted and cared for by good caregivers at the time of the incident. Damage comes when the injuries are inflicted by those to who one looks for love and protection, and there is no relief from the trauma. It is the emotional and psychological setting in which the sexual maltreatment occurs, and with whom it has occured, that makes the difference and causes lasting damage.

Children are born into the world absolutely dependent and helpless. They depend on others for food, warmth, cleanliness and protection from threat. Children's natural and healthy helplessness is transformed into terror and dispair when those needs are ignored, or when a parent plays "let's make a deal" with those needs.

Childhood should be a time of no-risk dependency. Many children, in desperation, learn to care prematurely for the expense of trust in others, emotional growth and self-acceptance. Unfortunately, try as they might, such children can never absolutely ensure their survival, simply because it is never absolutely within their control.

Try as they might, parents cannot always protect their children from trauma. A relative dies. The house burns down. The child witnesses a fatal car accident. The child is molested by someone outside the family and terrorized into keeping the secret. Yet, children can survive intact emotionally if adults provide them with a sense of safety and well-being in the aftermath of traumatic events.

Realistic, protective and compassionate treatment by adults can become more meaningful than the trauma itself, thus lessening its after-effects. However, when the source of the trouble is within the family, realism, protection and comapssion are usually in short supply. It is often not so much what actually happened that causes the "persistant negative effects" of trauma, as it is the absence of healing responses...what didn't happen afterward.

Suppose that in the midst of a tornado a child sought comfort and protection from his parents and was told, "What tornado? It's a beautiful day...Go outside and play." That's how crazy and unsafe the world seems to some children. Some survivors have tried to tell the truth about the abuse and were called liars or accused of being responsible for the abuser's behavior.

When a victim or survivor is disbelieved, shamed, threatened into silence, or when the disclosure is minimized or becomes cause for punishment, the trauma inflicted by willful ignorance compounds the original trauma. Children can withstand a lot with the help of other people; conversely, the denial or rejection of children's normal thoughts and feelings about trauma can cause as much pain as the original trauma.

To minimize the damage of trauma, children also need protection from further harm. But in troubled families it is not in the abuser's best interest to teach the child how to prevent further abuse. The nonprotective parent who denies or minimizes the abuse is usually passive. The child is usually left on his own to figure out the best way to protect himself.

Survivors rarely, if ever, benefitted from the compassionate and reasonable reactions that would have lessened the effects of their troubled childhoods. Given the enormity of what didn't happen after their traumas, it isn't surprising that they entered adulthood numb and anxious, or both. Protective numbing and reactive anxiety are, after all, normal reactions to abnormal situations.

Clearly, people were not meant to be physically or sexually abused. Human beings are not equipped to understand abuse as it happens, not to feel the full force of their physiological response at the time. And they cannot, at that moment, find meaning in the experience of the abuse. Each of these important elements of accomodation can only happen later, in distinct stages.

Survivors commonly speak of how they endured trauma by pretending that their mind and spirit had gone to a safer place, leaving the body behind to endure the abuse.

Abused children abandon reality, dissociating mind from body so they won't be overwhelmed and their ability to cope won't be shattered. Even a relatively minor trauma can provoke dissociation until a person is later able to integrate the experience. "Later", in the case of chronic abuse, particularly where the child has no support, may mean years later.

In the short run, dissociation is a very effective defense, walling off what cannot be accomodated. Sometimes the actual memory of the abuse goes into deep freeze. An incident in the present may trigger strong feelings that really belong to an incident in the past. The survivor may become enraged by what merely annoys others, devastated when others are momentarily sad, panicked when others are just worried. Present events tap into a deep well of feelings whose source remains alusive.

When asked what the worst memory from their childhood is, many survivors reply, "My worst memory has yet to surface."

Sometimes only the feelings go into deep freeze. Some suvivors have perfect, excruciating detailed recall of the abuse itself, but are numb to their feelings. Their hearts are in deep freeze. They do fine when they are not provoked to feel too much. They may avoid friendships and romance, or enter into them only on their own terms. They believe their feelings are as troublesome and overwhelming today as their parents once told them they were. They are numb to feelings as a way to keep control.

Many survivors ask, "If I don't remember the trauma, or if I don't have strong feelings about it, isn't that better?" Dissociation eventually takes far more effort than it is worth. The more we try not to, the more feelings and thoughts assert themselves, unconsciously demanding our attention. It takes an enormous toll to keep perfectly legitimate memories and feelings about childhood trauma in deep freeze. In the long run, one is better letting the thaw happen, and with the support of others, participating in some manner of "cure" that will allow life to go on.

Some survivors don't know they have a highly recognizable and treatable anxiety disorder called Post Traumatic Stress Disorder (PTSD), which has been associated with survivors of the Vietnam War, the Holocaust, mass murders, natural disasters, rape, kidnapping, accidents, torture, and other extraordinary events.

People with PTSD often re-experience the trauma in their minds. When the memory brings on a physiological response or feeling this is called an abreaction. (The release of emotional tension through the recalling of a repressed traumatic event.) Often the situation that brings on the abreaction is reminiscent of the original trauma.

An abreaction could be triggered by something someone says, circumstances such as the press of a crowd, being left totally alone, a darkened room...or even a particular time of the year, smells, touch, tastes...or other things associated with the trauma. Suddenly, the survivor is transported as if in a time machine to the event of the original trauma and reacts with the emotional intensity that would have been appropriate then, though not now. During an abreaction it is difficult to distinguish "what was" from "what is".

Herein lies the Achilles Heels for survivors. They function well in many aspects of life until they encounter the events or circumstances that are likely to trigger abreactions: emotional vulnerability, physical illness or evasive medical procedures, struggles with authority figures, cultural oppression or abandonment, to name a few.

A person with PTSD lives with a persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. Survivors with PTSD may avoid any intimate connection, often resulting in feelings of detachment or estrangement from others. Survivors often have highly developed social skills and may seem to be extremely extroverted, but their dealings with others may preclude vulnerability. They can talk about movies or work or the weather, but they have difficulty expressing their feelings. Or, they may have constricted feelings. They may be unable to identify and express a wide range of emotions, particularly the anger, fear and sadness so closely associated with the original traumatic events.

Certain circumstances can make the disorder longer lasting and more severe. If a trauma is repeated, for instance, as in chronic physical or sexual abuse, then the disorder might persist more than it would after only one incident. Repitition does not make one immune to the consequences of trauma. Rather, it has a cumulative effect, as unresolved trauma is layered upon unresolved trauma.

Traumatic events that are human in origin seem to have more severe after-effects than natural disasters. Hurtful and frightening as it is to be raped by a stranger, or to be in the path of a natural disaster, the creation of a personal disaster by a loved one is vastly more bewildering and overwhelming.

Another circumstance that contributes to the persistance of PTSD is the victim's age. The younger the victim, the more vulnerable he is. The more developmental skills and life experiences uncontaminated by trauma a child has, the more he has to draw on in the face of trauma. When life goes well, and children are loved and protected, each day is like a deposit in a savings account. Neglect, repeated physical abuse or sexual assault...or other life-threatening events, make huge withdrawals on the account. The more a child has in the bank when the trauma occurs, the better the prognosis for a quick recovery. Small children who are repeatedly traumatized usually have few deposits and easily become emotionally bankrupt.

When the survivor is ready to deal with it, memories and feelings begin to reconnect. He or she remembers, with the mind and feelings, instead of dismembering through dissociation.

The beginning of reconnection is usually attibuted to the fortuitous occurence of a trigger - an event or circumstance obviously associated with or reminiscent of the original trauma. There must also always be the simultaneous occurence of a positive trigger before the reconnection can begin. For instance, the survivor may have found someone trustworthy to talk to (therapist, friend, partner, support group) and may finally feel safe and sane enough to explore and accept her feelings.

The pain and disorientation can be balanced by focusing on the positive trigger. During this process, survivors should ask themselves, "Why now? Why didn't I remember this two years ago? Five years ago?" The answer lies in the conjunction of this trigger, along with the negative one, which tells the survivor "you can afford to reconnect have the power, judgement, insight and support that you truly did not have as a child. It is safe enough."

Walling off parts of the trauma was once the solution to an unbearable situation. Eventually, it causes problems in the mind, heart and spirit, in one's relationships with the child within and others, and in one's work. Trauma, if left unresolved, is destined to be re-enacted in one of those vital aspects of the self.

To recognize that a mother is exploiting you for her own ends, or that a father is unjust and tyrannical, or that neither parent ever wanted you, is intensely painful. Moreover, it is frightening. Given any loophole, most children will seek to see their parent's behavior in some more favorable light. This natural bias of children is easy to exploit.

It is not just the child's body that is abused or neglected. Troubled families mess with a child's mind. Virtually all survivors believe that their ability to think, to intellectually master the challenges in their lives, was of of their greatest strengths as children. Like other coping mechanisms, their over-reliance on rationality fell into obsolesence and became one of their greater weaknesses.

Children struggle to make some sense of a loved one's abusive and neglectful treatment. If the child understood what abuse really was, a random and violent imposition of another's will onto a relatively helpless person, he would despair at such hopelessness and betrayal. Therefore, he uses every mental effort to make himself seem in greater control while transforming the abusive parent into the safe and loving caretaker he so desperately needs. Such lies of the mind require mental gymnastics.

Children don't do this thinking in a vacuum. In some situations they are told what to think. In most cases they are influenced by the abuser's faulty thinking and by the rationalization of the adults who passively enable the abuse to go on. Children hear what those powerful adults say and what they don't say.

On top of the abuse and neglect, denial heaps more hurt upon the child by requiring the child to alienate herself from reality and her own experience. In troubled families, abuse and neglect are permitted; it's the talking about them that is forbidden.

Minimization is a thinking error designed to protect the injured self, making one seem a little less injured. The need for it can lessen as the survivor can afford to embrace the full reality of the past. (Refraining from denial is an act of courage for survivors. They have to choose quite literally between being alienated from themselves and reality...or being alienated from family members who still deny abuse.)

In troubled families, the thinking around who is responsible is convoluted at best. Abusive parents externalize, blaming other people, places and things for their behavior. They compensate by controlling everyone around them. their heart of hearts...they feel out of control. They must blame others because it is too painful to take responsibility for their unhappiness. Children are easy targets because they cannot challenge their parent's thinking errors. Few children can argue when facing an enraged mother. Hearing accusations often enough, children come to believe that they are responsible for their parent's troubled behavior.

Unfortunately, children receive an internal psychological payoff when they believe the abuse is their fault...a false sense of power. The child can let the unfairness and danger of the violence shatter him, or he can tell himself, "I'm not frightened or angry or sad or helpless or innocent. There is nothing wrong with this situation. This is happening to me for a good reason. This is happening to me because I deserve it, because I provoked it, because I was put here on Earth to endure such things. There is really nothing out of the ordinary about this."

The child is doing the best he or she can do to make sense out of the abuse or neglect, by feeling guilty and responsible, thereby holding on to the illusion that he or she is in control of what is truly out of control. This illusion of power seems better than acknowledging that one has no power at all. Such pseudologic quells feelings of hurt, rage, terror, confusion or sadness...rationalizing them into a deep freeze.

The child's sense of guilt and responsibility is useful to the abusive parent, who believes he isn't abusive..that it is the child who forces him into being abusive. The nonprotective adults want the child to bear the guilt so they won't have to face the harm their neglect is causing. So...the dance of the violent family begins: Children are responsible for adult's behavior...adults are responsible for nothing.

Faced with random, senseless abuse, a child begins to think herself as inherently unlovable.

Believing oneself to be guilty, responsible, or in control of others' hurtful behavior can be a tenacious habit. Many survivors deal with any overwhelming experience - physical illness, abandoment by a friend or spouse, academic or job demands - by "comforting" themselves with the illusion that they are in fact in control and to blame. An enormous amount of energy is sapped by this irrational guilt.

Rarely do survivors see themselves as so powerful over the good in their own lives. Here, their parent's constant projection has left it's mark. Many survivors, convinced of their inherent worthlessness and inadequacy, look to other people, places and things for salvation. Only when they have the "perfect intimate partner, their dream house, or public recognition for their work" will they be redeemed. Of course, anything so powerful to save their lives might also destroy their lives, which brings the survivor back full circle to his original feeling of powerlessness. Reasponsible for all the pain in the world...he is inept at enjoying his own happiness.

Fantasy, as a coping mechanism can also be a weakness. Too often fantasies become more real than relationships. Survivors may fantasize a lot about what other people think or feel about them.

Trauma influences our ways of organizing in our minds what goes on out in the world. Survivors who have not fared well in life tend to think in sweeping generalities...people are either good or bad, with no gray area in between. Everything is "always" or "never", with no room for "doesn't matter much." In contrast, some survivors have thinking that is highly compartmentalized.

Children simply do not have the cognitive development or life experience for clear thinking in the face of trauma. Their thinking errors reflect their best attempt to comprehend the incomprehensible...when the truth wasn't offered or allowed. A first step to recovery, then, is to examine, challenge, and change these old ways of thinking about trauma.

The goal of sorting through the lies of the mind is to learn to take the abuse less personally, and thereby to feel safer. By looking back, the powerful adult mind can more objectively measure the powerlessness of the traumatized child.

Thinkly clearly may not be the entire answer, but it is an excellent and necessary beginning. Emerson wrote: "It is the oyster who mends its shell with pearls." But, unlike oysters, we are not solitary creatures. We mend one another as well as ourselves. Pearls of wisdom help us to take the next heal in the company of other people, feeling the effects of the trauma while we hold onto our life rafts.

Feelings begin in the body, not in the mind. Many survivors say, "I know what happened wasn't my fault, but I still feel somewhat unlovable and damaged. My self-worth is measured by how other people see me. My head knows that is wrong, but my heart feels differently. Thinking comes much more easily to's still a big risk to feel. If I ever started to cry, I'd cry a river. If I ever felt the terror of it all, I'd disintegrate into nothingness."

Children don't innately know how to repress their spontaneous responses. They have to be taught, and troubled parents are perhaps the best teachers of all. There are three iron-clad rules in the abusive home: Don't talk. Don't trust. Don't feel. To break any of them means risking rejection or punishment.

One of the few predictable aspects of a violent family is the unpredictablity of the parent's responses. Every time the child cries, he gets a different response. Soon he realizes that it is unsafe to cry. After a while, he keeps his feelings to himself and perhaps loathes spontaneity because it causes so much trouble.

Young children offer their feelings to adults as gifts, as their currency of exchange in intimacy. All they can do to be close to adults is to offer their feelings. When their feelings are ignored or rejected as wrong, bad, troublesome, sick, crazy or stupid...they feel rejected. The young mind reasons "since my feelings are unacceptable, I must be unacceptable, too."

Beyond teaching children to recognize and articulate their feelings, parents help children to contain and express feelings constructively. When children do not learn how to do this they may become overwhelmed by them, experiencing them as floods. They may come to fear or loathe their feelings.

Adults from abusive homes can also become pain-avoidant. Survivors attempt to control the people and events around them so that they will never feel pain again.

What is most tragic about pain-avoidant behavior is that it is a defense against something that has already happened and cannot be undone. A survivor cannot live fully in the present until he or she has the past in perspective. Sometimes being preoccupied and defensive about the pain waiting in the future is just a distraction from addressing the real pain in the past.

To be intimate is to risk pain. There are no guanantees. To miss years of loving to avoid the pain of loss is too high a price to pay.

Survivors attempt to flee from feelings about having been abused, from normal reactions to an abnormal situation. Because that situation was life-threatening in the past, some survivors mistakenly believe that to experience those feelings today would also be life-threatening, would bring on an emotional breakdown, a falling apart akin to death. They do not understand that the breakdown has already happened, when their feelings were preempted by shame.

A survivor can afford to look that "death" squarely in the face when he has people who will stand by him, as well as the insight and power he did not have as a child. When it is finally safe enough, the survivor will remember the memories and feel the feelings about the trauma. Such a "thawing out" is a second chance, an emotional reincarnation. Still...the first sensations that have been repressed or avoided all of one's life can feel like a tidal wave.

When he is ready, the thoughts and feelings return. In response to what has been uncovered, he often feels great anger at the betrayal itself and the injustice and randomness of the violence.

Underneath that anger is a terror and helplessness that is more difficult to experience than the anger. ("Maybe it wasn't as bad as I remember. Maybe I'm just exaggerating.") This can go on for a long time, but with the help of others, the survivor will eventually accept that the trauma was as bad as he knows it was.

Profound sadness follows. This compassionate acceptance of "poor me" and the mourning of the losses that the trauma created eventually lead to resolution.

When the losses engendered by trauma are fully mourned, the trauma loses its power over the survivor. Instead of the emotional breakdown they feared...survivors experience an emotional breakthrough! Completing the grieving process means divorcing the trauma from one's sense of identity and self-worth.