Children who have been victims of maltreatment can develop emotion regulation problems that affect many areas of their lives. Some survivors of abuse can experience symptoms of posttraumatic stress, anxiety, and depression throughout life. Coping and relational skills learned in childhood form the foundation from which future behaviors evolve. It has been hypothesized that women who survived maltreatment, in the form of physical or sexual abuse or neglect, will have sexual challenges in adult relationships. To test this theory, Alessandra H. Rellini of the Department of Psychology at the University of Vermont conducted a study involving 192 women ranging in age from 18 to 25.

The study focused on how emotional regulation, childhood maltreatment, sexual expression, sexual satisfaction, and relationship intimacy were associated in the context of committed adult relationships. The women in the study completed online surveys describing the type of abuse they experienced and their level of intimacy, affectionate expression, and sexual satisfaction in their current relationships. Rellini found that the more severe the childhood abuse was that the women experienced, the more unsatisfied they were in their adult relationships. This was true with respect to general and sexual relationship satisfaction. The severity of abuse also directly predicted the severity of emotional regulation impairment, which could be indirectly influential of satisfaction.

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In contrast to Rellini’s predictions, however, the findings did not demonstrate any association between emotional regulation impairment and intimacy or emotional expression. This was rather surprising, as previous research has suggested that abuse survivors tend to have challenges sustaining emotionally healthy sexual relationships. One factor that may have contributed to these results is the broad categorization of abuse used in this study. Specifically, this study did not examine sexual abuse separately from emotional or physical abuse to determine each type of abuse’s independent effect on emotional regulation. Despite this limitation, Rellini believes her findings provide evidence of unique correlations between childhood maltreatment and adult relationships for women, but more work needs to be done. “Research is now needed to explore the stability of such findings over time in order to determine the time course and sequencing of change between the studied variables,” she said.

Reference:
Rellini, Alessandra H., Anka A. Vujanovic, Myani Gilbert, and Michael J. Svolensky. Childhood maltreatment and difficulties in emotion regulation: Associations with sexual and relationship satisfaction among young adult women. Journal of Sex Research 49.5 (2012): 434-42. Print.

Destructive parentification is a behavior in which a parent transfers the emotional or physical responsibility of parenting to their child. Some parents turn to their children for emotional support and expect their children to fill emotional voids. Other parents who engage in destructive parentification may expect their children to fulfill physical obligations such as caretaking. These behaviors diminish the appropriate boundaries between a parent and child that are necessary for a child to develop his or her own identity. Additionally, boundaries that are blurred can expose children to events and circumstances that they are emotionally and physically unprepared to handle. This type of parentification can have significantly negative outcomes for children. Research has shown that children who are the victims of parentification, which is considered a form of abuse, have higher rates of externalizing and internalizing problems in childhood and adolescence than those who do not experience parentification.

When victims of parentification become parents themselves, the risk of the cycle continuing is extremely high. However, few studies have examined how maternal behavior in adult victims of childhood parentification affects future generations. To explore the relationship between maternal behavior and childhood psychological development, Amy K. Nuttal of the Department of Psychology at the University of Notre Dame in Indiana assessed 374 pairs of mother-child participants through the first 3 years of the children’s lives. The mothers were evaluated for childhood parentification in their own families of origin and and for mixed histories of emotional abuse, sexual abuse, or physical abuse.

Nuttal found that the women with destructive parentification were less responsive to their children at 18 months than those with no history of parentification. The unresponsiveness was predictive of externalizing behaviors in the children at 36 months. When Nuttal examined the effect of the father’s presence, she discovered that the participants who maintained a relationship with the father of the child had significantly lower levels of prior parentification than those who had no relationship with the fathers. Nuttal also found that previous parentification directly predicted low levels of maternal warmth in the participants, which indirectly predicted negative developmental outcomes for the children. She added, “This finding suggests that facilitating the development of maternal contingent responsiveness among mothers with a history of destructive parentification may promote more adaptive child development in the next generation.”

Reference:
Nuttall, A. K., Valentino, K., Borkowski, J. G. (2012). Maternal history of parentification, maternal warm responsiveness, and children’s externalizing behavior. Journal of Family Psychology. Advance online publication. doi: 10.1037/a0029470

Related articles:
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Importance of Coping Skills, Part 2: Building Resilience
How to Teach Children Emotional Intelligence

While the terms “pedophile” and “child molester” are often used interchangeably, they do not mean the same thing. A pedophile is a person who is attracted to children, but not all people with pedophilia molest children. Many individuals who are attracted to children never act on their attraction, and some seek help in order to keep from harming children.

Pedophilia is considered by some to be one of the most difficult social problems to understand. The 5th edition of the Diagnostic and Statistical Manual classifies pedophilia as a paraphilia, distinguishing it from pedophilic disorder: It is diagnosable as a mental health condition when it causes distress to the affected individual or to someone who is unwilling or unable to consent. Thus, according to this classification, having an attraction to children and not acting on it does not indicate a mental condition.

New research shows that pedophilic disorder may be neurological in nature, lending further support to the position that an attraction to children is not a choice. Some may find this difficult to accept, as those who do act on their desires and molest children have the potential to cause serious and lasting harm to many children. They may repeat their crime over and over until stopped by the criminal justice system. Many people may believe that, once caught, people who molest children deserve to spend the rest of their lives in prison, but the reality is that many of these individuals will eventually be released.

Upon release from prison, offenders are often required to enter rehabilitation programs, which are meant to redirect pedophilic urges and help a person refrain from harming children. These programs are often viewed with skepticism, as many believe that a person who molests children cannot be rehabilitated and that pedophilic urges will always lead to the sexual abuse of a child. However, there are several perspectives on the issue.

The Difference Between Pedophilia and Child Molestation

Psychological perspectives on child molestation vary greatly, but experts agree that most people who molest children fall into one of four categories:

1. Children or teenagers under the age of 16 who are sexually curious and may experiment with younger children.
2. Adults who have a brain condition, intellectual disability, or other mental health issue.
3. Individuals who have an antisocial personality and may use children sexually but have no particular sexual desire for children.
4. Individuals who are older than 16 and experience ongoing sexual desire for children. Sexual desire for children, or pedophilia, can be identified and treated or controlled with therapy and medication.

Ninety-five percent of all known instances of child molestation are committed by people with pedophilia. Other individuals may molest children for the above reasons, out of sexual frustration, or in order to maintain power or exert control.

Though nearly all those who molest children have pedophilia, many people with pedophilia will never molest a child, and some work to eliminate their attraction to children through various forms of treatment and therapy.

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Non-Offenders

Dan Savage, who frequently writes on the topic of human sexuality, has published several accounts of people who, despite their attraction to young children, avoid being alone around children and are able refrain from committing acts of molestation. It is generally acknowledged that it may take a significant amount of self-control to avoid offending and that pedophiliac inclinations typically mean a person with pedophilia will find it difficult to have a healthy sexual relationship.

In several European countries, Savage points out, people experiencing a sexual attraction to children are often able to seek treatment confidentially. In the United States, however, an individual who discloses pedophilic tendencies may be arrested, as therapists and physicians are required by law to report anyone who poses a threat to children. This law, in addition to the stigma surrounding pedophilia and the limited number of resources available to those seeking help in the U.S., is likely to discourage non-offenders from seeking professional help, help that may enable them to continue to keep from offending.

Free and confidential prevention and treatment programs–such as Germany’s Prevention Project Dunkelfeld–may help those who are attracted to children refrain from acting on their desires. Some European countries do have lower child molestation rates than the United States, and this fact may be connected to the availability of treatment.

Many people who are attracted to children are horrified and frightened by their preferences and attempt to do everything they can to keep from harming a child. They may wish to attend therapy, explore ways to curb their desires, or take medication. Making treatment available and accessible to individuals before they offend may reduce instances of child molestation.

Chemical Castration

Chemical castration is one method that may keep child molesters from reoffending. Many states in the U.S. offer voluntary chemical castration in exchange for earlier release. Some states, such as California, mandate castration for offenders with multiple convictions as a condition of release. The treatment has been shown to greatly reduce sexual desire in men who are attracted to children and to lower rates of recidivism.

Those who have not yet harmed a child and who are committed to avoiding doing so may find relief from their desires through chemical castration. In some cases, an antidepressant, which may have the effect of further limiting one’s sex drive, is also prescribed.

Sexual desire cannot be completely eliminated by castration, a fact that leads many individuals to question the efficacy of the treatment and the risk of releasing offenders who may still experience some sexual desire for children. Another objection stems from the fact that the person undergoing treatment must be relied on to take their medication regularly. However, chemical castration has been shown to be effective for many individuals and thus is likely to protect many children who would potentially be victims of sexual abuse.

Group Therapy

Many therapists use group therapy as a type of treatment for people with pedophilic tendencies. Groups can provide a safe environment to discuss inappropriate and harmful urges, and the support of a group of individuals facing similar challenges may give some people the strength to avoid offending or reoffending.

However, when someone is involuntarily enrolled into group therapy and has no particular desire to stop offending, a support group can become a different environment. Other members may, knowingly or unknowingly, support a high-risk offender’s further attempts at molestation. But because mandated group therapy may be of benefit to some convicted offenders or those who are at risk for offending, group leaders may not wish to withhold a potentially helpful treatment from anyone. They may, however, choose to carefully screen participants prior to program entry and during treatment.

Aversion Therapy

Aversion therapy pairs an unpleasant stimulus such as an electric shock, pinch, or flick along with a pleasant stimulus. Sex offenders may use aversion therapy to attempt to eliminate their attractions to children. While this therapy can be effective, it often poses ethical problems, as therapists cannot shock their patients. It can also be difficult to maintain consistency with this type of treatment. Further, when aversion therapy does work, it is unlikely to do more than eliminate the attraction to children. It likely will not help people develop an attraction to age-appropriate adults if they do not already experience such an attraction.

Fake Porn

Psychologists have still not reached an agreement about whether pedophilia is a sexual orientation or a mental illness. Those who believe it is a sexual orientation may advocate the use of fake porn, depicting animated or CGI children, as a way for those with pedophilic tendencies to achieve sexual release. Some therapists have reported that this method has been successfully used to reduce an individual’s desire to molest a child.

However, other therapists point to studies demonstrating the effect pornography can have on sexual desire and express concern that such pornography may actually create or increase a desire to sexually abuse children. Many also question the ethics of making such pornography, even when it does not involve actual children.

References:

1. Early Diagnosis and Effective Treatment. (n.d.). Retrieved from http://www.childmolestationprevention.org/pages/focus_on_the_cause.html
2. Goode, S. D. (2010). Understanding and addressing adult sexual attraction to children: A study
   of paedophiles in contemporary society. New York, NY: Routledge.
3. Jenkins, P. (2004). Moral panic changing concepts of the child molester in modern
   America. New Haven, CT: Yale Univ Press.
4. Kaplan, M. (2014, October 5). Pedophilia: A Disorder, Not a Crime. Retrieved from http://www.nytimes.com/2014/10/06/opinion/pedophilia-a-disorder-not-a-crime.html?_r=0
5. Kincaid, J. R. (1998). Erotic innocence: The culture of child molesting. Durham, NC: Duke
   University Press.
6. Nanos, J. (2014, March 1). Can Chemical Castration Help Pedophiles Tame the Beast Within? Retrieved from http://www.bostonmagazine.com/news/article/2014/02/25/chemical-castration
7. Schwartz, C. (2011, December 7). What Science Reveals about Pedophilia. Retrieved from http://www.thedailybeast.com/articles/2011/12/06/what-science-reveals-about-pedophilia.html
8. Seto, M. C. (2008). Pedophilia and sexual offending against children: Theory, assessment, and
   intervention. Washington, DC: American Psychological Association.

If you haven’t read the novel yet, you might be 50 shades of curious about why Fifty Shades of Grey is the most-talked-about tale in print currently.

A quick search will reveal that the romance between the main characters, Mr. Grey and Miss Steele, revolves around bondage, discipline, dominance, submission, sadism, and masochism (BDSM). In fact, Christian Grey appears to really only get satisfaction from sex when it involves inflicting pain or dominance over his partner, which, following criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) used by mental health professionals to make diagnoses, could be considered a mental disorder called sexual sadism.

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The DSM IV-TR states that “sexual sadism involves acts (real, not simulated) in which the individual derives sexual excitement from the psychological or physical suffering (including humiliation) of the victim.” In order to officially be diagnosed with sexual sadism, individuals must meet the following criteria:

1)    “Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.”
2)    “The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.”

In the first novel of the series, Christian Grey appears to engage in sexual sadism only with consenting participants (like Anastasia Steele, the main female character), but he openly admits to being abused (including sexual abuse) as a child and teenager and appears to be at least somewhat distressed by the fact that it’s difficult for him to have a “normal” relationship. He even explains to the character Anastasia Steele at one point that this is just the way he is, almost with sorrow. And although he does have “normal” or “vanilla” sex with Anastasia, he makes it obvious that he prefers sex that involves pain and pleasure at the same time, always with him dominating.

Anastasia also admits to herself that there is something unusual about Christian and his sexual preferences, but she lets her desire for him take over, and she hopes that she can make him want a “normal” relationship with her. She herself has issues with low self-esteem and confidence, which is perhaps why she is so drawn to the seemingly overly confident Christian. Both characters appear to function as well as the average person in their fictional world, but both have issues that could potentially need to be addressed by a professional if they lived in the real world.

So it appears that one of the main characters of Fifty Shades of Grey may have a diagnosable disorder related to sexuality, or at least has abnormal sexual preferences and a traumatic past that hasn’t been resolved yet. He has major difficulties maintaining any lasting romantic relationship, and yet the relationship between Christian and Anastasia seems to have been received in a somewhat positive light, considering the large following of readers.

The Experts Weigh In
Several mental health experts have offered their insight into the unusual relationship found in Fifty Shades of Grey (and the two other novels in the series). Reef Karim, a board-certified psychiatrist, the founder and medical director of the Control Center for Addictions, and author of Why Does He Do That? Why Does She Do That? and host of the new show Broken Minds on the Discovery channel, said that the novel is definitely making people think about normal and abnormal sexuality and possibly changing some people’s minds.

He said in an e-mail that the main question people are wondering is, “What is normal and abnormal sexual behavior, and when is aberrant sexual experimentation and behavior considered a mental health diagnosis?” “The really interesting part of psychiatric diagnoses is that many are based on a behavioral spectrum where the interruption of an individual’s social, relational, occupational, and functional life is a key factor in making the diagnosis,” Karim said. “This book has become a literary piece of pop culture that is challenging many to review their thoughts on normative and ‘out of the box’ sexual behaviors.”

He said that there could be concerns about a link between sadomasochism (S&M) and childhood abuse as well, since that is mentioned in the novel. “There is definitely a connection, but many people with no psychiatric or psychological history report enjoying BDSM primarily as a novel and alternative way to connect with each other,” Karim said.

Despite (or because of) the unusual relationship involving pain and pleasure (and emotional issues), many women appear to be captivated by the novels. Karim suggests this is because women enjoy having sexual fantasies, but that doesn’t necessarily mean they want the type of relationship found in the novel to become more than a fantasy. If anything, women might be more prone to sexually experiment during or after reading the novels.

However, he doesn’t think the novel is capable of completely changing sexual norms, so sexual sadism and sexual masochism will most likely still be considered mental disorders according to the DSM in the future. “I believe the novel opens up the conversation of BDSM, kink and sexual norms, but it’s much more in the curiosity range than actually changing research-driven professional medicine,” Karim said. “Expecting an increase in sex shop purchases is different than changing a clinical manual.”

Karim explains further why the novel is so appealing to women (and men), even with the dysfunctional (and sometimes even depressing) personalities of the characters. “In regards to sexual research, many women fantasize about submission, and many men fantasize about dominance,” he said. “Even though men and women are more equal than ever in regards to occupation and finances, we are still very different sexes, and definitive gender and role-based fantasies do exist,” he added. “Many people in our society have hidden (or not so hidden) fantasies involving kink, S&M, or altered sexual behavior. 50 Shades of Grey has opened up the conversation of previously hidden sexual desires and fantasies of many women.”

He said the novel could help couples become more creative in their sex lives, but going to any extremes is generally not beneficial. “The introduction of BDSM can add to a couple’s sexual tool box, but occasionally it can get out of control,” Karim said. “When extreme behavior leaves the bedroom or involves extremes in the bedroom, it can negatively impact the relationship. I’ve treated couples who use BDSM as a novel, fun experience in a healthy and intimate way, and I’ve treated other couples or individuals who became obsessed with the act or re-created a previous abuse history with a lot of painful markings.”

Overall, the BDSM series is encouraging men and women to discuss sexuality more openly with each other. “The book mentions childhood abuse and difficulties with self-esteem that contribute to the psychological make-up of these characters, but it has also found a way to tap into the S&M lifestyle curiosity shared by many men and women,” Karim said. “It may actually normalize the behavior, when done in moderation, as not something strange but perhaps just another form of sexual expression. Life isn’t always black and white; sometimes it’s fun to live with a little grey.”

Kari Tabag, a licensed clinical social worker, works with adolescents and college-age men and women and has read the series. She said the novel has passages that hint at mental health issues like posttraumatic stress, codependency, BDSM, and alcoholism.

Although she agrees that the novel can improve people’s sex lives through fantasy, role play, and experimentation, the sexual expectations people might have after reading the series might be set too high, leading to disappointment. Also, she emphasizes that the actual relationship depicted in the series is very unhealthy in many ways. “Christian and Anastasia’s relationship is not a healthy one. They are codependent and are too enmeshed with each other,” Tabag said. “A lot of women are codependent and are what I call ‘daddy hungry.’ This novel depicts two people who have abandonment along with trust issues.”
There are even more unhealthy aspects of the fictional relationship, according to Tabag:

• When Anastasia finds out that Christian only dates women with brown hair, it is a dead giveaway of his childhood abuse and abandonment. In fact, Anastasia refers to him as her “boy,” which is not healthy.
• Anastasia repeatedly feels that she is not worthy of Christian and vice versa.
• Christian is obsessed with Anastasia and even follows her to another state when she visits with her mother.
• They both are looking for someone to take care of rather than focusing on healing themselves. A healthier relationship involves two people who have their own separate, independent personas, making them well-established, well-rounded, self-reliant individuals.
• Christian wants Anastasia to give in to him and give up all control, and he lavishes her with gifts as a reward.

Although the relationship in the novel is not healthy, BDSM is not necessarily as terrible as it’s made out to be. Tabag suggests our society is not necessarily mature when it comes to accepting and understanding sexual preferences outside of ‘man on top.’”

Viewpoint From a Submissive
Kasi Alexander, the author of several books and short stories about alternative lifestyles, such as Becoming Sage and Saving Sunni, has herself been involved in the lifestyles of polyamory, BDSM, and power exchange. She currently identifies herself as a “slave,” and the partner in her polyamorous relationship is the “master”; she could also be referred to as a submissive. She said in an email that the relationship between Christian and Anastasia is not necessarily a model of the typical BDSM or power exchange relationship. The characters themselves are also not typical. For example, Christian Grey was abused as a child and became involved in BDSM at 15, and he now avoids “vanilla” sex and relationships.

“Very few people in the lifestyle immerse themselves so deeply that they have no desire for a relationship outside the parameters of power exchange,” Alexander said. “The ones who do are using the lifestyle to mask other personality defects, not the other way around. Accepting your dominant or submissive tendencies does not kill the desire for intimacy, closeness, or connection.” Also, the character of Anastasia Steele is low in self-esteem, self-worth, and confidence, which is not usual for submissives, Alexander said.

“Many people assume that submissives give up all responsibility for themselves, are doormats that cannot stand up for themselves, and so are taken advantage of by predatory dominants,” Alexander said. “That couldn’t be further from the truth. Submissives are stereotypically extremely strong, capable people. Many of them crave submission as a way to temporarily escape the huge responsibilities they take on in their “vanilla” lives.”

Alexander adds that the BDSM lifestyle can even be considered therapeutic in different ways. “In my own relationship, we have used our power exchange to work on my self-image and body issues, increase my self-confidence, and achieve many goals, including writing and publishing three books (so far),” she said. “Other kinky people that we know use sensation play as therapy or catharsis to work through feelings of inadequacy, childhood abuse issues, and various kinds of mental health issues.”

The BDSM element of 50 Shades of Grey just takes the typical romance/erotic novel a little further. “Women have a genetic inclination toward alpha males, so we love our fictional heroes to be large, powerful, and a little scary—someone who has the ability to hurt us but doesn’t,” Alexander said. “And almost all BDSM play is based on the intensification of physical experiences. So the fantasy of the physical ‘danger’ (intensity of experience) goes along with the mental domination of having a strong alpha male taking over your life. It’s erotic, even if it’s not what we want in our actual day-to-day lives.”

She said BDSM and power exchange have the potential to make relationships more sexually fulfilling, but just like in any relationships, it’s a matter of communicating wants and desires. And just like in other bad relationships, abuse and manipulation can happen, but that is a matter of individual personalities and relationships, not a characteristic of BDSM as a whole. She said it’s important to make a distinction between mental conditions and different sexual preferences and alternative lifestyles. “The most important aspect of the mental disorder consideration is the difference between true sadism and kinky sadism,” Alexander said. “A vast majority of ‘sadists’ in the BDSM community derive no pleasure from inflicting pain unless the recipient is enjoying the experience, whereas a true sadist is not concerned with the benefit of the other person.”

She believes that people will eventually become more accepting of these types of lifestyles and realize that they can be beneficial to people who can learn how to make them work.

“More education is needed to show people that polyamory is not cheating, BDSM is not abuse, and power exchange is not manipulation,” Alexander said. “The important thing to keep in mind is the benefit for the people involved. BDSM and power exchange can be done badly and for the wrong reasons, but they can also be used for personal, professional, and spiritual growth and for the enhancement of relationships.”

Related articles:
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Adults who have survived childhood abuse are more likely to experience mental health problems than those who were not abused during their youth. Depression, anxiety, panic, posttraumatic stress, eating and food issues, and substance abuse are just some of the psychological conditions that these survivors face. Another consequence of childhood abuse is diminished physical health. Research has shown that negative psychological well-being decreases physical health and can lead to serious health problems, including hypertension and heart disease. But few studies have examined how specific types of childhood abuse affect physical health directly.

To address this gap in research, Cathy Spatz Widom, Ph.D., of the Psychology Department at John Jay College at the City University of New York recently conducted a study that sought to determine the link between three individual types of abuse and later physical health problems. Widom analyzed data from adults who had been abused prior to their 12th birthday. The average age of the participants was 41. Each participant underwent a complete physical examination and blood test in adulthood. Based on documented reports of the abuse, Widom compared how sexual abuse, neglect/maltreatment, and physical abuse in childhood affected the participants’ health in adulthood.

She found that the adults who had experienced neglect and maltreatment had poorer oral and visual health as well as impaired airflow and increased risk for diabetes. The adult survivors of sexual abuse were more likely than the other participants to develop oral health issues and hepatitis C. They also had higher rates of HIV and malnutrition. Those who had survived physical abuse were also at increased risk for malnutrition and diabetes. Although some of these conditions could be attributed to maladaptive coping techniques, such as smoking, drug or alcohol use, and poor nutrition, the findings clearly show that adults who have survived childhood abuse are still at increased risk for significant physical health problems. Widom believes that these findings have strong clinical implications. She said, “Understanding the mechanisms that place abused and neglected children at higher risk for these adult physical health outcomes will help focus these efforts.”

Reference:
Widom, C. S., Czaja, S. J., Bentley, T., Johnson, M. S. (2012). A prospective investigation of physical health outcomes in abused and neglected children: New findings from a 30-year follow-up. American Journal of Public Health, 102.6, 1135-1144.

The process of trauma recovery includes developing a narrative to one’s history, compartmentalizing who is accountable for what, and integrating old material into a new paradigm. Intrafamilial abuse, particularly child abuse, is often layered and complex. The locus of the early stages of the work tends to be the perpetrator of physical, sexual, or emotional injury. However, throughout the progression those who failed to protect slowly come into focus.

Survivors express uncertainty around the parent who did not harm them but did not protect them either. As therapists, our energy is directed towards ensuring that the burden of abuse lies in the hands of the perpetrator. Clarity and relief are common responses to unraveling culpability.

The circumstances under which there is a nonoffending parent (or community) who also failed to protect a child can complicate recovery. Clients report strong feelings towards those who did not keep them safe and express confusion about who or what this person is. “Are they an abuser? Did they love me? If they did how could they have allowed this to happen? How can you watch your own child being abused and not intervene? Is there something wrong with me?”

Abuse in its various forms can sometimes be less convoluted than the failure to act, respond, or protect. It is a complex endeavor to absorb exactly how one can avoid acting in response to someone harming a child. Professionals such as teachers, therapists, or anyone who has regular contact with children are required to report suspected abuse.

In some states, law enforcement is required to intervene on some level with domestic violence, while child protective services views domestic violence as a threat to the well-being of the children in the home. Implicit in such requirements is that there is some culpability in failing to protect. Yet defining nonoffending parents can be arduous for both clients and therapists.

Perhaps our task as helping professionals is to develop our own understanding of parents who, for whatever reason, do not or cannot protect their own children. I often find myself aligned with my clients’ confusion. While not always completely clear or simple to define, categorizing abusive acts as wrong seems more clear than failure to protect, and even more so if the person who did not intervene was a parent.

There appears to be some collective agreement that those outside of the family have a responsibility in safeguarding those who cannot defend themselves. It feels a bit more muddled in applying these rules to family members. How do we define a parent who is otherwise loving and warm but has knowledge of the abuse and does not intervene? Even if the parent is disengaged or emotionally absent, how do we work with our clients in defining them? Is a failure to act a form of abuse in itself, or is the nonoffending parent a victim as well?

The ethics of community response to failure to protect remains convoluted. In addition, working with our clients in understanding this aspect of their story is a delicate pursuit. The circumstances of the client’s story can occasionally provide the answers to our questions. Most of the time, context fosters few explanations. Perhaps in this case, the conclusion lies within the question — bemusement exists because this is a complex issue.

Normalizing a lack of clarity and difficulty in compartmentalizing the nonoffending parent or family member is difficult for all of us, not only the survivor. Hopefully, acknowledgment of the layers and intricacies of intrafamilial abuse is a starting point for all of us, and at least survivors have a partner in their journey for answers.

There are a number of different experiences that can cause a child to develop maladaptive coping tendencies. Children who are emotionally or physically abused, neglected, or raised in extremely stressful environments may internalize their emotions. Likewise, children who have experienced sexual abuse may dissociate as a way of defending themselves from the psychological harm that results from sexual abuse. Trauma suffered in childhood increases the risk for dissociative behaviors. Auditory hallucinations are one form of dissociation and are evident in individuals with mental illnesses such as schizophrenia. To better understand how childhood trauma, dissociation, and hallucinations are related, F. Varese of the School of Psychology at Bangor University in the United Kingdom recently led a study comparing the dissociative behaviors, childhood traumas, and cognitive discrimination of 45 individuals with schizophrenia and 20 participants with no prior hallucination history.

Because dissociation is recognized as a pathway for hallucinations and an outcome of childhoodtrauma, Varese sought to determine if the frequency and type of trauma influenced hallucinations and the capacity to determine real and imagined events in the participants. Using a signal detection performance task (SDT), Varese found that the participants with a history of childhood sexual abuse were the most likely to experience dissociative behaviors that resulted in hallucinations. The frequency of abuse was directly related to the level of dissociation, with the most severely abused participants exhibiting the highest levels of hallucinations. The findings also showed that the participants with infrequent hallucinations had lower levels of abuse and dissociation than those who experienced more hallucinations. Varese believes that further research is needed to determine if adult stress and trauma rather than childhood trauma contributed to the intermittent hallucinations in the participants with sporadic dissociative behaviors. In sum, these results suggest that a better comprehension of the type of abuse suffered may be the key to developing effective treatment strategies for individuals who experience hallucinations. Varese added, “Future research should examine whether other cognitive processes associated with both dissociative states and hallucinations (e.g., deficits in cognitive inhibition) may explain the relationship between dissociation and hallucinatory experiences.”

Reference:
Varese, F., Barkus, E., Bentall, R. P. (2012). Dissociation mediates the relationship between childhood trauma and hallucination-proneness. Psychological Medicine, 42.5, 1025-1036.

Psychotherapists and clients who are working with issues of dissociation talk about being grounded a lot. What we usually mean by grounded is the experience of feeling present and aware in our bodies and being able to interact with the world around us with a clarity of our senses. There are even formulas that seem to have developed for how to be present—“feel your feet on the floor, your butt in your chair, and breathe.” Sometimes this is enough, but often it’s not.

Moving your body is a much faster and more reliable method for becoming grounded. Although movement in general is often helpful for restoring awareness to the body and breaking free of dissociation, centered and well-organized movement is even more useful.

Try the following experiments to see if you can notice the benefits of grounding movement:

1.  Jump up and down and side to side while waving your arms wildly. What was that like for you? What did you notice physically and emotionally, both during and after the exercise? How satisfying was that?
2. Now try standing with your feet shoulder width apart and begin rotating in your hip joints. Twist side to side, letting your arms follow the movement of your torso. (Some people find it helpful to imagine that they are a washing machine). What was this like? What were your physical and emotional sensations? Did you find this movement satisfying?

People typically report that the second exercise helps them bring their surroundings into focus and reduces anxiety and fearfulness. They feel more grounded and less dissociated.

This works because it offers an organized and nonthreatening way to quite literally expand the body and bodily awareness.

Dissociation is a flight response to a perceived threat. Checking out, via either partial or total amnesia, or switching into another part of the self, makes awareness of the threat disappear. This is a very handy skill for small children who are not able to adequately protect themselves. This is less useful for adults who have developed habits of dissociating—whether the threat is present in the moment or remembered.

The problem with dissociation is that adults, who are capable of protecting themselves, lose access to that protective ability when they split. As a colleague of mine likes to say, if there’s a tiger in the room and you pretend it’s not there, that doesn’t actually make the tiger disappear. Dissociation doesn’t make you more safe, and it actually makes you less safe.

But, clients often tell me, if I don’t dissociate and I choose instead to be present, then I’ll be stuck in my fears—how does being petrified make me any safer? Good point, I reply. They’re right, after all. Being frozen with fear is not any more effective than dissociating is for dealing with that oncoming tiger. What is effective for safety is being present and grounded.

Here’s another experiment you can try which demonstrates this point:

1.  Imagine that you’re afraid. It might help to recall a time when something scared you—perhaps a loud noise, a spider, or something else that frightened you a little bit. Notice what happens in your body (pay attention to your breathing, posture, and points of tension).
2. Now imagine that you’re safe and satisfied. Pull up a memory of an experience of being warm and secure and loved. What’s going on in your body this time?

In general, people report that when they’re afraid, their bodies constrict and collapse, their stomachs tighten, breathing becomes shallow, jaws clench, and they notice tension in their arms, chest, legs, and/or back. When doing the second exercise, they typically feel their bodies open up and relax.

The feeling of safety is a lot like the feeling created by the washing machine exercise at the beginning of this article. This suggests that being present in our bodies is the path to safety. Instead of having to only choose between dissociation and petrifaction, people working with dissociation can make use of movement to come into a state of groundedness and safety.

Childhood emotional maltreatment (CEM) can have lingering effects. Adults who suffered mistreatment as children often struggle emotionally and socially throughout their lives as a result of being neglected or emotionally abused. Although there is an abundance of literature and research that focuses on the negative impact of childhood maltreatment (CM) in general, there is little available clinical evidence documenting the devastating effects of CEM. It has been well established that CM, including sexual and physical abuse, can increase the risk for depression, anxiety, substance misuse, and a host of other emotional problems. However, for adults who experienced CEM, one of the most difficult challenges they face is cultivating a healthy romantic relationship.

CEM can significantly deteriorate one’s self-esteem and erode an individual’s ability to trust another person. Beliefs about one’s value and worth and a bond of trust are the foundation of a healthy intimate relationship. This foundation can be further compromised when CEM survivors exhibit body-image dissatisfaction, which is often manifested through disordered eating behaviors. To provide more detailed evidence of the long-term consequences of CEM on relationships, Dana Lassri of the Stress & Risk and Resilience Research Lab at the Department of Psychology at Ben-Gurion University in Israel examined the stability and satisfaction of intimate relationships in a sample of college students with a history of CEM in two separate studies. Lassri found that CEM directly impacted relationship fulfillment in the participants by way of self-criticism. Specifically, Lassri discovered that the participants with CEM had extremely low levels of self-value, exhibited difficulty coping with stress, and held negative attitudes about life events.

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The results also revealed that the individuals who had posttraumatic stress due to the CEM were less able to realize their self-worth and had significant problems maintaining relationship satisfaction.  This could be caused by internalizing behaviors due to the abuse or by a child’s inability to properly comprehend their circumstances. Either way, Lassri believes that even though these findings were gathered from college-age individuals, the behaviors could potentially worsen throughout adulthood. Lassri added, “Over time, this tendency might be consolidated, becoming a defining part of a person’s personality; and ultimately derailing relationships in general and romantic relationships in particular.”

Reference:
Lassri, D., Shahar, G. (2012). Self-criticism mediates the link between childhood emotional maltreatment and young adults’ romantic relationships.” Journal of Social and Clinical Psychology 31.3, 289-311.

People who have suffered childhood trauma are at increased risk for psychological problems resulting from extreme stress. Borderline personality disorder (BPD) is one such condition that has been linked to severe childhood trauma. When the trauma is inflicted by a caregiver, the child’s ability to cope is significantly impaired. The effects of unhealthy coping, attachment dysfunction, and emotional regulation can affect many areas of the child’s life as they continue into adulthood. Affect dysregulation is the inability to control one’s moods and emotions and has been linked to BPD and other mental illnesses. Underregulation of emotions is expressed by lack of control, extreme emotional overwhelm; while overregulation is the result of numbing and is exhibited by an inability to express emotions. To determine which of these factors is more indicative of BPD in adults who suffered trauma during childhood by their primary caregiver (TPC), Annemiek van Dijke of the Delta Psychiatric Hospital in the Netherlands conducted a study of 472 clients with a diagnosis of BPD.

The participants’ levels of affect regulation were documented and they were evaluated for various forms of TPC, including sexual abuse, physical abuse, and emotional trauma. Van Dijke found that 63% of the participants had experienced some form of TPC and that those with underregulation had more symptoms of BPD than the participants with overregulated affect. Although the study did not consider other factors that could influence BPD, such as family history, other traumas, and the mental health of the caregivers, the results clearly emphasize the importance of examining emotional regulation, and specifically underregulation, in clients with a history of TPC.

The findings also showed that the participants with TPC were at increased risk for posttraumatic stress (PTSD). But Van Dijke noted that no research has been conducted to determine exactly how specific forms of TPC affect the severity of PTSD symptoms or how they are indirectly affected through affect regulation as a result of TPC. In sum, Van Dijke believes that these results can benefit clients who have suffered TPC by educating clinicians on the importance of helping clients build more secure relationships and develop healthier emotional expressions.

Reference:
Van Dijke, A., Ford, J. D., van Son, M., Frank, L., & van der Hart, O. (2012). Association of childhood-trauma-by-primary caregiver and affect dysregulation with borderline personality disorder symptoms in adulthood. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0027256

Love is one of the most elemental of emotions. It is a building block of some of our deepest relationships and a component in many of our happiest days. Yet the ability to freely give and receive love is a fragile skill, which traumatic experiences can all too easily dent or damage.

Learning how to be loved is a vital part of your healing. Here are a few things to think about as you regain your ability to accept someone’s care, concern, and nurturing.

Part of learning how to be loved again is learning how to interact with people who express kindness, care, concern, nurture, and attention. Because you have experienced a traumatic experience, you have learned that people are capable of great cruelty. To avoid experiencing cruelty again, a part of your mind may have decided to ensure that you will never be hurt again. One of the ways that your mind tries to protect you from future cruelty is to assume that people are dangerous. This assumption in turn results in you leaning towards mistrust, avoiding vulnerability, and shying away from emotional intimacy.

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One way to practice opening yourself up to love is to practice opening yourself up to trust, vulnerability, and intimacy. But you have to make sure that you are practicing this with a safe person: someone who will not be cruel, let alone abusive, to you.

First, assess the level of vulnerability you open yourself up to if you take in the token of love.

• A compliment from a coworker is a token of kindness that carries with it a low level of vulnerability.
• Accepting a birthday present from a friend is an expression of care that has a bit more risk.
• Taking in a statement of love from a nonabusive romantic partner is a higher level of vulnerability.
• Accepting a dinner invitation from a friend who has been cruel may be a much higher level of vulnerability than taking in a statement of love from a partner who has been trustworthy.

Once you assess the level of vulnerability, take a moment and decide if this is a level of vulnerability you are safe with. If the vulnerability exceeds your level of healing, claim your right to do what is wisest for you, and back off or decline the token of love.

Consider the giver’s genuineness and accuracy. Is this someone with whom you have enough history to know their usual level of genuineness and accuracy? If you’re not sure, consider only accepting an expression of love that is low on your level of vulnerability. If you do have enough history with this person, then let their history of genuineness and accuracy help you decide whether to take in the expression of care, concern, or love. Someone who has proven to be genuine, truthful, and accurate is most likely extending an expression of love that is worthy of trust.

Consider whether there could be an ulterior motive. How would the giver of this token of love benefit from you accepting it? Could this benefit be damaging to you? When accepting an expression of love that makes you beholden or indebted to someone, think long and hard whether there could be an ulterior motive on the behalf of the giver.

If the expression of care is within your range of vulnerability, and is from a genuine and accurate person who does not have a damaging ulterior motive, then take in the love. Practice taking a deep breath while reminding yourself that you are actively healing one of the most fundamental of skills. Recognize that this is a moment in which you are being cared for, loved, and nurtured. Try not to miss these moments of kindness and care.

If you can believe the giver’s statements of friendship, respect, or love, then rejoice in the fact that someone believes these positive things about you. If believing these messages of love is out of your reach right now, then simply practice listening. Avoid disagreeing and don’t rebut the person’s opinions of you. Give voice to your gratitude, and express your thankfulness for this token of love.

If you are working on your healing with a therapist, try using that relationship to practice accepting care. I hope you have experienced your therapist to be the kind of genuine, accurate person with whom it will be safe to practice accepting love. Those questions about how you are, how your week was, and so on, are not just the standard questions of therapy: they are also tiny moments when therapeutic care and concern are being expressed. If nothing else, practice listening to these statements of care without disagreeing. I encourage you to take in the warmth of your therapist.

Individuals who are “symptomatic” of post-traumatic stress disorder (PTSD) may seem sick, crazy, or irrational. They might appear dissociative, clinically depressed, anxious, highly reactive, or rageful (or all of the above). In addition, it’s common for an individual to cultivate a sense of self-loathing for displaying these characteristics. During treatment, both therapist and survivor may agree that these symptoms are a mark of disease, making it their goal to alleviate the symptoms. Alternatively, both may choose to believe that these symptoms are an expression of health versus illness. This could enable more directed treatment, internal compassion, decreasing fear of symptoms, and a relationship between survivor, therapist, and trauma.

According to the DSM IV (American Psychiatric Association, 1994) criteria for diagnosing PTSD includes intrusive memories, thoughts, or dreams of an event, a sense of reliving the event, and intense distress in response to both internal and external cues that resemble an event(s).  Individuals may thus avoid triggers or cues, increase isolation or have a sense of ‘waiting for the other shoe to drop’ (a foreshortened future), and detachment.  Sleep difficulties are common; mood liabiality, and hyper vigilance are also common (American Psychiatric Association[DSM-IV], 1994). When a survivor feels hopeless, confused, and self-loathing because of the manifestations of their trauma, the initial layer of treatment is frequently the unraveling of self-loathing for the expression of symptoms themselves.

To begin to evaluate trauma and develop a relationship with its influence on survivors, we can draw from the practice of narrative therapy and the concept of externalizing a problem, which recognizes that the person is not the problem; the problem is the problem (Playful approaches to serious problems: Narrative therapy with children and their families. Freeman, Jennifer C.; Epston, David; Lobovits, Dean New York, NY, US: W W Norton & Co. (1997). xvii, 321 pp.). PTSD, as a character in a survivor’s life, uses symptoms as tools to protect us, remind us of our core values, and ensure that what happened before won’t happen again. The trauma response could even correspond to the level of violation on self and values; from this perspective, a profoundly disturbing event calls for a profoundly disturbing response. Flashbacks, dreams, invasive thoughts, and triggers provide specific information about the violation the client’s event(s) infringed upon them. These also exemplify the concept of “stuck points” in Trauma-Focused Cognitive Behavior Therapy (Akin-Little, Angeleque (Ed); Little, Steven G. (Ed); Bray, Melissa A. (Ed); Kehle, Thomas J. (Ed), (2009). Behavioral interventions in schools: Evidence-based positive strategies, School Psychology (pp. 325-333). Washington, DC, US: American Psychological Association, xi, 350 pp.)

The aspect of a survivor’s past that is troublesome can be quite specific and idiosyncratic. Groups of people exposed to the same event often are disturbed by different parts of it. Interpersonal trauma such as child abuse, domestic violence, or sexual assault may render someone feeling responsible for what happened to them, feeling dirty or shameful, betrayed, foolish, unimportant, or completely exposed.  Trauma might be conveying to someone that they are at fault for an assault because it wants the individual to have a sense of mastery or agency.  Helplessness is too passive, so self-blame is an acceptable tone to assume. An individual might also begin to associate a traumatic feeling of betrayal with a feeling of foolishness, ensuring s/he does not trust people too easily and maintaining inner safety.

The way in which a survivor expresses their PTSD can vary widely and presentations can be very complex and oppressive.  It is common for survivors to blame themselves for their past experiences, and they often enter into treatment with a great deal of shame because they feel they should have “gotten over it” without help. A therapist can offer some relief from shame by viewing survivors’ symptoms as useful, even critical to their treatment.

Through the process of healing, a survivor can learn to establish trust in self to clearly identify his/her core values, to reflect his/her significance in the world, and to maintain personal safety. The character of trauma will refrain from presenting images (flashbacks and dreams) when the stuck point has been identified, and will cease making statements that the individual is culpable for what happened once there is a demonstration of mastery over the event. It will hold back on invasive, persistent thoughts once the survivor is able to look at the event rather than avoiding it.  PTSD symptoms reflect individual values and provide explicit guidance for healing; if therapist and client are willing to work with trauma, and absorb the information it has to offer, it will not invade with such rigor.