Child Abuse: Perspectives from a Gendered Trauma-informed Lens

Abstract

Child abuse that involves maltreatment of children by parents and/or trusted adults, including child sexual abuse can be conceptualized with the trauma-informed lens for both the survivor and the perpetrator. The trauma-informed lens is a significant departure from the prevailing DSM view of trauma and rests on the understanding of trauma being pervasive, undetected and disabling. Conventional clinical practices can be damaging to this already vulnerable group of service users. A paradigmatic shift is necessary in clinical services for child abuse survivors. The trauma-informed clinician takes a nuanced clinical perspective of the past that has survived into the present with an appreciation of survival mechanisms and constructs such as dissociation, attachment, relational trauma and development of the self. There is more importance on preventing retraumatizing and causing harm to the client, and avoiding mis-steps in the clinical interview. Resourcing, empowerment and a humane approach to the clinical rendezvous is recommended for the trauma-informed clinician engaged in working with survivors of child abuse. A gendered perspective that appreciates gender as a social construct and patriarchy as the mechanism that traumatized both the male and the female ideal enables clinicians to work with the survivor without othering the perpetrator. The article also addresses important considerations for working with survivors of child abuse, including betrayal trauma and the relational field in therapy.

Introduction

The PTSD lens has consistently focused on trauma as discrete or continuous events, as defined in the criteria of diagnostic categories such as Trauma-Related Disorders (DSM-5). The movement for including a clinical understanding of complex trauma into the classification system began with the work of Judith Herman and Bessel van der Kolk in the l990s. Around the same time, in the US, the trauma-informed care perspective gained momentum with the reports of several groups that represent service users, the Substance and Mental Health Services Administration (SAMHSA), the President’s New Freedom Commission on Mental Health and the work of Harris and Fallot in designing trauma-informed mental health delivery systems. ¹ The conceptualization of trauma being limited to discrete, remembered events and its psycho-physiological consequences, is fundamentally flawed and this is reflected in the recent introduction of Complex PTSD in ICD-11. ICD-11 attempts to include disorders of self as one of the defining features of a complex form of PTSD; however, has not done away with the genesis of trauma in discrete events. The category Complex PTSD is also defined by ICD-11 as different from other disorders like Personality Disorders, which may have a traumatogenic etiology as well.

The Trauma-informed Lens

Clinicians harbor a proclivity to define trauma as events that have transpired in the service user’s life. However, trauma is not defined in terms of what happened, but more about what has stayed on as an imprint of the past into the present. A more clinically nuanced definition of trauma by Saakvitne et al. ² considers “trauma” as experience(s):

Trauma is the unique individual experience of a (single) event, a series of events, or a set of enduring conditions, in which: the individual’s ability to integrate his or her emotional experience is overwhelmed (i.e., the ability to stay present, understand what is happening, tolerate the feelings, or comprehend the horror), or the individual experiences (subjectively) a threat to life, bodily integrity or sanity.

We tend to view traumatic events and experiences as being overwhelming, outstripping the capacity to adapt, resulting in lasting negative impacts on the soma and psyche. What often fails to be recognized is the adaptive mechanism that got shaped out of the traumatic experience and enabled survival of the organism. Trauma is transformative, for better or for worse. From a salutogenic perspective, ³ trauma can also be conceptualized as the genesis for adaptation and resilience. It is thus critically important for the trauma-informed clinician to appreciate the adaptive nature of trauma responses.

Fallot and Harris ⁴ view trauma as “pervasive, highly disabling and largely ignored.” Trauma plays a deterministic role in health—not just psychological but also physical symptoms such as inflammation, auto-immune disease may have a genesis in trauma. The trauma response is neurobiological, hence trauma responses have little to do with choice and willpower. The usual response to trauma in most cultures is to retell the story in an attempt at catharsis, thus risking re-traumatization. Trauma shapes the identity and narrative of one’s life and thus becomes deeply embedded as a character structure, often traceable to one’s social location. The task of understanding how an individual’s trauma is entrenched in their physical, physiological, psychological, emotional and mental mechanisms demands a sensitive, perceptive and compassionate clinician. The question is not one of diagnosis; the question is one of understanding and relating current symptoms to the individual’s “trauma.” The clinical challenge is as much in the process of deriving the understanding as it is to reaching a conceptualization that is trauma-informed. As summarized by Butler et al., ¹ to be trauma-informed is to:

understand the local and global mechanisms of violence and oppression and how they influence the lives of all service users of mental health services.

appreciate symptoms in survivors not merely as clinical psychopathology but also as a fundamental neurobiological response aimed at adaptation and survival.

participate in the paradigmatic shift from pathologizing the service user to a nuanced, humane enquiry into the adverse experiences that shaped their personality.

recognizing sources of further harm to the service user via trauma-uninformed clinical services and thereby minimizing all possible sources of re-traumatization.

Checklists and standard psychiatric interviews equip the clinician in developing insight into events that happened to the individual that led to the current psychopathology. This diagnostic exercise largely aids in pharmacological treatment and becomes the guiding principle for the first few sessions in psychotherapy; I shall define this as a clinical curiosity. There has been an established link between adverse childhood experiences and functionality in adult life. While this clinical curiosity may be therapist-driven, clients might also be curious to understand and develop a coherent narrative about themselves—why they are the way they are. This direct strategy of digging in deep to explore the past and create a narrative can be retraumatizing, causing harm to the client, (and sometimes for the therapist as well) thus violating the principle of Primum non nocere (Do no harm). Adverse childhood experiences include broadly abuse and neglect. These adverse events are experiences of the individual of things that happened to them that should not have happened (abuse) and things that should have happened but did not (neglect). Both sets of experiences are traumatic and can be defined as Big T and small t (abuse) and traumas of omission (neglect).

The trauma-informed manner of clinical interviewing is significantly different from a conventional psychiatric history taking—there are no algorithms, no clinician-driven checklists, or screeners. It is instead a slow, nuanced and guided exploration of the landscape of one’s traumatic past; a process that warrants care, resourcing and empowerment over clinical curiosity. As the clinician meanders through the trauma landscape of the individual, they learn the relatively lesser importance of the events that shaped the mantle and the crust, as compared to the hidden landmines and fault lines that have stayed on from the tectonic events of the past. The challenge for the trauma-informed clinician is to both map and avoid stepping on the landmines and fault lines in the initial phase of therapy.

Dissociation and Trauma

To be trauma-informed is to incorporate the construct of dissociation in the case conceptualization. Dissociation may be simply defined as the ability to compartmentalize experience (van der Kolk et al., as cited in Dutra et al. ⁶ ). While the psychiatric view of dissociation espoused the “narrow” view of dissociation, many theories of dissociation construe it as a continuum from adaptive to maladaptive dissociation. Dissociation in the contemporary perspective is a natural ability of the brain to narrow down awareness and attentional processes in the aid of resource conservation. Whatever creates intolerable distress and is a threat to survival can be compartmentalized and stored in subliminal awareness. Dissociative capacity also encompasses the ability to engage in trance states such as those involving focused attention, creativity, daydreaming and intense absorption or flow. Viewed as an adaptive capacity, Putnam ⁵ (as cited in Dutra et al. ⁶ ) defines the defensive functions of dissociation as:

behavioral automatization that enables multitasking behaviors

affective and informational compartmentalization, that lead to a lack of integration or implicit awareness of affective and informational material in the aid of survival and conservation.

Identity alteration and depersonalization, that enable detachment of “parts” of personality or between cognition and affect.

The trauma lens views dissociation as a neurobiological response to alter unbearable reality into an experience that is less intolerable and this response persists as clinical symptoms. Dissociation is thus the footprint of trauma. The child abuse survivor whether in minorhood or adulthood when presenting in a clinical setting, would have tell-tale signs of dissociation. It is therefore imperative for trauma-informed clinicians to be conversant with signs and symptoms of dissociation in children and adults. The field of dissociative studies since the 1980s has been informed by developmental psychology, neurobiology and interpersonal neurobiology and dissociation theories. ⁷ Much research on dissociation in the past two decades has been on adults rather than on children (Putnam ⁵ as cited in van der Hart & Dorahy ⁷ ). However, research has also identified that the pathway of association between trauma and dissociation lies in the developmental trajectory of the self. Dissociative processes have been found to affect and be affected by organization of the self. Not only maltreatment in the form of child sexual abuse, physical abuse, neglect and harsh parenting, other parenting practices that rigidifies a false sense of self for the child, are associated with disorganizations in the experience of self and consistently found to be correlated with childhood dissociation. ⁸ Pathological dissociation can be difficult to discern from adaptive dissociative mechanisms in childhood, that are noticed in states such as fantasy proneness, pretend play, hyper hypnotizability, etc.). Thus dissociative states do not have the same clinical interpretation nor do adults and children have comparable cognitive capacity to notice discontinuities in self-awareness. Dissociation in children can therefore be more challenging to identify.

Relational Abuse and Child Abuse

Emotional abuse can be broadly considered to be a pathological relationship. The seat of most traumatic experiences are relationships, especially those with attachment figures. This kind of trauma is often conceptualized as small t trauma as opposed to discrete, well-recognized traumatic experiences known as Big T trauma. Small t is the trauma of numerous, invalidated, experiences of hurt, betrayal and neglect perpetrated knowingly or unknowingly by an attachment figure. Emotional abuse is not a single event caused by a stranger, it is the result of countless betrayals by a significant other. These betrayals are often disbelieved in (by self and others), counted as exceptions, and pinned as a sign of “maladaptive” or malignant love. It is this hope of love that keeps the individual in the emotionally abusive relationship, and the abuser locked in a perpetual pattern of relational abuse. Child abuse is a form of relational abuse perpetrated by an adult on a minor. The perpetrator may be a parent or an adult who has been entrusted care of the child, or has been perceived by the child in a trusted caregiving role. The trauma of abuse by a trusted attachment figure involves several layers of traumatization including an apparently adaptive way of relating to the perpetrator(s) and thereby others. This relating style continues far beyond the relationship with the perpetrator(s) and pervades the attachment system of the individual. Childhood trauma thus persists not only as flashbacks, avoidance/safety behaviors and behaviors triggered by the HPA axis, but also in the way the survivors relate in their intimate relationships. The attachment wounds get shaped into relational patterns into adulthood and are consequently labelled clinically as “personality disorder.” In its essence, this way of relating presents itself clinically as “complex trauma,” which at its core is a disorder of “self,” or a problematic manner in which the individual has learnt to organize their experiences of self. Thus, early attachment wounds may shape the nervous system to be vigilant for trust breaches, and this is continued into adult relationships as critical, fault finding and “not good enough” ways of relating to significant others. Survivors may develop a more preoccupied/avoidant manner of attachment, and thus engage in overcaring, pursuing or distancing and disregarding others. Yet there may be pockets of safety, depending on the reservoir of any trustful relationships that may have existed through their traumatic pasts. Attachment styles are not discontinuous, absolute patterns but can be conceptualized on a continuum of relating and safety. Individuals often exhibit mild shifts from an overly anxious ambivalent/preoccupied style to a more avoidant/dismissive style. The most problematic way of relating to others that presents as a significant challenge in therapy is the disorganized attachment pattern, which can be conceptualized to be on one extreme of the continuum. The disorganized attachment state is one of confusion and chaos, where safety and vulnerability are both experienced simultaneously leading to rapid fluctuations in implicit decisions to trust. This pattern of vacillating between attachment states and disengagement states shows up in one of the toughest ways in relationships including therapeutic relationships—the oscillation between idealization and devaluation. Thus survivors of child abuse, may become adult recipients of relational trauma further into adulthood or embody the perpetrator introject and become a perpetrator. Survivors are often fraught with relational trauma throughout adulthood until corrective relational healing occurs to establish safety and interconnectedness as the foundations for a functional adult life. There is ample research that shows intergenerational transmission of parenting that involves childhood maltreatment. ⁹ This completes the self-perpetrating nature of trauma—unhealed trauma infiltrates into the next generation as perpetrating adults and parents who engage in child abuse and/or child sexual abuse or even other forms of relational abuse such as intimate partner violence. This is the enormous potential of relational trauma to live on as intergenerational trauma.

A Gendered Lens to Relational Trauma

A gendered lens to emotional abuse often takes the form of feminist and/or queer affirmative psychotherapy to empower the less dominant gender in the emotionally abusive relationship. While therapy for gender-based violence (GBV) often needs to empower the “abused” to leave the relationship, it also errs on othering the perpetrators of GBV. This othering does little to address the other side of the picture; the story of how the “victimized” became the “victimizer.” A gendered lens to understanding the complex world of trauma survivors warrants the understanding of masculinity which concurs with a feminist-based understanding of oppression. ¹⁰ Gender is a social construct and includes beliefs, stereotypes, emotions and behaviors socially conditioned to belong to a particular gender. Masculinity is thus also a “socially constructed gender ideal for men and male roles” (Thompson & Pleck ¹¹ as cited in Neilson et al. ¹² ). This is the untold, repressed story of masculinity that is shaped by the violent mechanism of patriarchy (trauma strain, Pleck ¹³ ). Trauma has an uncanny way of perpetuating whether in the victimized or victimizer. Unless there are enough clinicians and healers who could disrupt these stories of undetected abuse in relationships, emotional abuse stemming from gendered roles will persist as intergenerational or transgenerational trauma. Gender intersects with other social locations like race, caste, sexual orientation, social class and thus there is no one kind of masculinity, as Connell ¹⁴ suggests four different types—hegemonic, subordinate, marginal and complacent. According to Badinter ¹⁵ (as cited in Fernandez-Alvarez ¹⁰ ), the male ideal is:

“a true man” lacks femininity. He is neither a baby, a woman, nor a homosexual. Thus the male ideal is one who has successfully repressed his emotionality and humaneness.

“Manliness” is measurable in terms of being superior to others. This perpetuates the ideal who is constantly in the pursuit of dominance and social comparison as per standards of prestige and power.

A “man” needs to be strong, autonomous, powerful and stoic, thus lacking any “feminine” weakness.

A man is socially allowed to engage in violence in the pursuit of superiority and strength.

The idea of masculinity is a historical, cultural, social construction of patriarchy and it is a bodily apprenticeship (Bourdieu ¹⁶ as cited in Fernandez-Alvarez ¹⁰ ). Masculinity as conjured by patriarchy, emerges from the socially constructed superiority of the male body and is supposed to be enacted and reenacted in body-based expressions of power—aggression, rape, violence and adrenaline-pumping sports. The idea of masculinity does not exist in nature, nor is it a natural product of consciousness. The idea of masculinity itself is a transgenerational small t. This invisible form of power that has oppressed human civilizations and perpetuated historical traumas, is the root of emotional abuse as we see in current times. Perpetrators of emotional abuse often lack a sense of self, a sense of boundaries, often have multiple fault lines in the structure of their personalities, warranting diagnoses such as DID or Personality Disorders—thus clinically check listing themselves as individuals with complex trauma.

Childhood Abuse and Forgetting

Child sexual abuse often does not leave behind any physical trace of the crime, least of all any acknowledgement by the perpetrator. It is most often invalidated by parents or other significant adults. It is often dismissed or disregarded by the perpetrator and by other adults as a figment of the child’s imagination, or a “false memory.” Freyd ¹⁷ enlightens us that the principle of betrayal trauma is: “See no betrayal. Hear no betrayal. Speak no betrayal.” This invalidation of betrayal by adult caregivers creates an information block that also leads the child to believe “no betrayal.” Freyd rationalizes the forgetting of childhood abuse as a natural information block that enables the survival of the child who is at the mercy of the perpetrating adult. However, the forgetting of childhood abuse is not one of suppression or absolute forgetting, but about the memory of the experience being pushed out of explicit or declarative memory, thus entering into the realm of implicit or body-based memory.

The Relational Field of Therapy with Childhood Abuse Survivors

The antidote to relational trauma exists in relationships that offer safety, security, compassion and love. Needless to say, the “corrective emotional experience” that therapeutic relationships serve to provide is a cornerstone of trauma-informed work. The landscape of the therapeutic relationship in trauma-informed work can be tumultuous and scarred. Both client and clinician enter into the therapeutic relationship with a sense of risk. Taking from Saakvitne et al. ² and Courtois and Ford ¹⁸ labels this as Risking Connection:

Risking Connection refers to both the traumatized client and to the professional helper: Both personally take a risk when they form a relationship (connection) that aims to help the client to overcome the terror, helplessness, and horror of surviving traumatic events and their aftermath.

There is also an inherent risk for the clinician in underestimating the power of the relational work. If we believe we can walk through this transformational fire of healing with our stoicism intact, our humanity not moved, our hearts not burnt by love, we are likely to be thrown off our seats when we encounter some people in our practice or that one client who visits us once in a lifetime—leading to an intense exchange of intimacy and humanity. It is this deconstruction of the clinical relationship as an engaging humane relationship that has been the advocacy for numerous trauma-informed therapists like Judith Herman, Christine Courtois and Bessel van der Kolk.

Transference and countertransference, enactments in the therapeutic relationship are often the guiding lights in understanding the landscape of the individual’s trauma. Trauma-informed supervision encompasses this strong relational field that not only provokes the client’s trauma responses but also churns trauma responses in therapists. Supervision is critical in navigating the work with childhood abuse survivors.

Conclusion

The trauma-informed lens in working with childhood abuse survivors represents a paradigmatic shift from the conventional clinical interview fueled by curiosity into life events of the individual. This shift represents a nuanced, neurobiology-informed understanding of the survivor to prevent re-traumatization and thus underscores the importance of safety, resourcing and empowerment as primary clinical goals. The importance of trauma-informed constructs such as dissociation, relational trauma, attachment and betrayal trauma for the trauma-informed clinician is paramount. It is also imperative for clinicians to have an understanding of both the abused and the abuser as part of the perpetuating cycle of trauma. Thus, a gendered lens to understanding trauma is extremely useful in conceptualizing client presentation and enabling a shared understanding of their worlds. The relational field in working with childhood abuse survivors needs supervision to avoid pitfalls and crises.