I was inspired by the recent McMaugh and colleagues (2024) article on working with continuing incestuous abuse to look for more research into best practice when working with survivors who are still being accessed by their perpetrators. Unfortunately, I found very little recent research in this area, which I suppose testifies to the bravery of the professionals who dare to write and speak about it. You inspire this student, ISSTD members!
I have put together a small variety of articles on a more general theme of working with ongoing risk or trauma as helpers. I hope they are of interest and find you well.
-Charlotte
McMaugh, K., Roufeil, L., Salter, M., & Middleton, W. (2024). Incestuous Abuse Continuing into Adulthood: Clinical Features and Therapists’ Conceptualisations. Journal of Trauma & Dissociation. Advance online publication. http://doi.org/10.1080/15299732.2024.2341221
Abstract:
Prolonged incest, where children are sexually abused by familial perpetrators into adulthood, has been documented in clinical and criminological scholarship, however it is often overlooked in research, policy and practice approaches to familial sexual abuse. This article draws on interviews with ten Australian therapists about their clinical work with clients subject to incestuous abuse continuing into adulthood. It outlines their descriptions of these cases, the nature of the reported abuse and factors that facilitated prolonged and ongoing incest, including at the time of therapy. The therapists and their clients were female. The clients were highly dissociative and experienced significant psychiatric and medical comorbidity, and extensive socio-economic disadvantage. Reported abuse was sadistic, ongoing, often involved multiple perpetrators, and sometimes had links to organized abuse. Therapists’ conceptualizations of the factors related to the abuse included: enmeshed and disorganized attachment to the perpetrator; symptoms of severe dissociation; having absent, abusive or non-protective mothers; and social isolation which limited help-seeking. The study concludes that attachment, trauma and dissociation-informed therapy is essential, while further research is needed to further explore effective interventions and responses to this clinical cohort.
Walker, H. E., & Wamser-Nanney, R. (2022). Revictimization Risk Factors Following Childhood Maltreatment: A Literature Review. Trauma, Violence, & Abuse, 24(4), 2319-2332. http://doi.org/10.1177/15248380221093692
Abstract:
Revictimization research, to date, has primarily focused on sexual revictimization (i.e., child sexual abuse and adult sexual assault), which has resulted in a lack of understanding of trauma revictimization more generally. Specifically, it is unclear what factors are placing individuals with a history of child maltreatment (i.e., sexual abuse, physical abuse, and witnessing intimate partner violence [IPV]) at greater risk for subsequent adult victimization (i.e., sexual assault and IPV). Existing theoretical and empirical work on revictimization suggest that multiple risk factors are likely present within this framework (e.g., posttraumatic stress symptoms [PTSS], emotion dysregulation, and risk-taking behaviors). Prior research has suggested that PTSS are often linked with these other risk factors, and it is possible that the development of PTSS following child maltreatment may be related to the development or maintenance of additional factors that increase the likelihood of revictimization. The purpose of this review was to synthesize findings regarding risk factors that place maltreated individuals at greater risk for adult revictimization. Approximately 228 studies were identified following a thorough search of the peer-reviewed literature using multiple databases (PsycINFO, PILOTS, and Google Scholar). Each study was critically analyzed for relevance. The included studies were used in our review of prevalence, specific risk factors that have been identified, and unanswered questions in this literature. PTSS were noted to be particularly important in the revictimization framework, and thus, a novel model of revictimization was also proposed where PTSS are illustrated as being associated with the development and maintenance of other factors within the revictimization framework.
O’Connor, C., & Surgenor, P. (2023). How self-injury affects psychotherapists: A qualitative study. Counselling and Psychotherapy Research. Advance online publication. http://doi.org/10.1002/capr.12731
Abstract:
Introduction: Interpretative phenomenological analysis (IPA) is used to explore how people make sense of their personal and social world, although a search of recent literature suggests that it has not been applied to better understand self-injury (SI). The goal of this paper was to employ an IPA methodology to gain a deeper understanding of the impact witnessing the physical manifestations of SI has on therapists.
Method: The study recruited a purposive sample of nine English-speaking psychotherapists. Questions designed to relate to the participant’s experience of witnessing the physical manifestations of SI were piloted with non-participating psychotherapists whose experience matched those of the sample. Individual interviews were conducted by the primary researcher.
Data Analysis: Analysis involved the hermeneutic circle, moving between the part and the whole to capture and record the unique experience of the individual participants. This entailed the following: reading and re-reading the transcripts; initial noting; developing emergent themes; connecting emergent themes; and pattern identification across cases.
Results: Two superordinate themes were identified that encapsulated how participants experienced, perceived and understood their own reactions to clients’ SI presentation. The first, Shock, included the subordinate themes of Controlling reactions, Managing physical revulsion, Therapeutic holding and Revisiting and ruminating. The second, Responsibility, included the subordinate themes of Client responsibility, Professional responsibility, Personal responsibility and Responsibility for hope.
Implications: Implications relate to core training for psychotherapists, the focus on continuing professional development, and the policies and procedures needed to support psychotherapists.
Implications for practice and policy
- The current focus on addressing mental anguish and psychological distress in training should be augmented with training around exposure to traumatic injuries to the human body, including open wounds, cuts and burns. Preparing psychotherapists on how to respond to the physical manifestations of self-injury (SI), how to hold their emotions to preserve the relationship with the client and how to effectively debrief would avoid the extreme reactions reported by the participants in this study and also potentially reduce the risk of vicarious trauma or post-traumatic stress disorder. This training should also extend to peer supervision.
- While introducing an SI component to initial training would be a positive step to reducing the type of emotional responses shared by the participants in this study, the logical follow-up would be to include training on exposure to SI and the potential consequences in continuous professional development (CPD). Three areas in particular that such CPD could focus on include the impact of ‘holding’ or being a container of emotion, the need for self-reflection and continual self-care.
- Based on the experiences of participants in this study, current policies and procedures related to the management of SI presentations do not go far enough to support individual psychotherapists at a personal or professional level. To address the sense of personal and professional responsibility, frequently augmented with the risk of death by suicide and all associated implications, policies around supervision should be a priority.
Snellingen, J. F., Carlin, P. E., & Vetere, A. (2024). Is It Safe Enough? An IPA Study of How Couple Therapists Make Sense of Their Decision to Either Stop or Continue with Couple Therapy When Violence Becomes the Issue. Behavioural Sciences, 14(1), 37. http://doi.org/10.3390/bs14010037
Abstract:
Background: Couple therapists will encounter couple violence in their practice at some point. In this context, one of the main questions they must address is whether to continue with conjoint sessions. This study explores how couple therapists make sense of their decision whether or not to continue with conjoint sessions when violence has become an issue.
Methods: This qualitative study used four semi-structured focus groups and Interpretative Phenomenological Analysis (IPA) to analyse the data from the twelve experienced couple therapist participants. Results: Our IPA analysis led to three main group experiential themes across the focus groups: (1) Is it safe enough? (2) Do we have a joint and regenerative project? (3) Three key sources for sense making.
Conclusion: Partner violence challenges the realm of couple therapy. This article explored how the couple therapists orient themselves and grapple with decision making when violence becomes an issue. The article offers unique insights regarding what the therapists orient themselves towards and how they try to form an impression of whether to continue conjoint sessions. We outline immediate clinical implications and propose measures for building individual and organisational capacity regarding “clinical sense making”. Suggestions for further research are also addressed.
Yim, S. H., Lorenz, H., & Salkovskis, P. (2023). The Effectiveness and Feasibility of Psychological Interventions for Populations Under Ongoing Threat: A Systematic Review. Trauma, Violence, & Abuse, 25(1), 577-592. http://doi.org/10.1177/15248380231156198
Abstract:
Current views of psychological therapies for trauma typically assume the traumatic event to be in the past. Yet, individuals who live in contexts of ongoing organized violence or experience intimate partner violence (IPV) may continue to be (re)exposed to related traumatic events or have realistic fears of their recurrence. This systematic review considers the effectiveness, feasibility, and adaptations of psychological interventions for individuals living with ongoing threat. PsychINFO, MEDLINE, and EMBASE were searched for articles that examined psychological interventions in contexts of ongoing threat of either IPV or organized violence and used trauma-related outcome measures. The search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on study population, ongoing threat setting and design, intervention components, evaluation methods, and outcomes were extracted, and study quality was assessed using the Mixed-Method Appraisal Tool. Eighteen papers featuring 15 trials were included (12 on organized violence and 3 on IPV). For organized violence, most studies showed moderate to large effects in reducing trauma-related symptoms when compared to waitlists. For IPV, findings were varied. Most studies made adaptations related to culture and ongoing threat and found that providing psychological interventions was feasible. The findings, albeit preliminary with mixed methodological quality, showed psychological treatments can be beneficial and should not be withheld in the context of ongoing organized violence and IPV. Clinical and research recommendations are discussed.
Matthews, C. (2022). Acknowledging Soul Loss from an Indigenous Perspective to Promote Healing in Prison. Clinical Social Work Journal, 51, 143-152. http://doi.org/10.1007/s10615-022-00858-8
Abstract:
People incarcerated in the United States suffer disproportionately higher rates of substance use and mental health diagnoses than the general population. Treatment as usual is not sufficient, as evidenced by extremely high recidivism rates. Established links between trauma, depression and criminal behavior make it apparent that incarcerated people have many vulnerabilities underlying their maladaptive behaviors. The author’s use of self and an Indigenous perspective illustrate the concept of soul loss, which is when a part of one’s vital essence fragments to escape the full impact of anguish from a traumatic event. Soul loss exacerbates shame, hopelessness, and an overall visceral sense of spiritlessness evidenced by feelings of emptiness and disconnection. Indigenous wisdom can provide a nuanced understanding of incarcerated individuals’ moral and emotional experiences. From this perspective, it is essential to balance head and heart wisdom for a holistic appreciation of the human experience. Addressing soul loss in a supportive therapeutic context promotes self-compassion, forgiveness, and the integration of fragmented parts for healing, ultimately reducing relapse and recidivism. This paper shares a journey of growth, demonstrating how clinicians may use integrative psychotherapy for people who are incarcerated to heal within the intersubjective space and themselves.
Schwartz, L., Nakonechna, M., Campbell, G., Brunner, D., Stadler, C., Schmid, M., Fegert, J. M., & Bürgin, D. (2022). Addressing the mental health needs and burdens of children fleeing war: a field update from ongoing mental health and psychosocial support efforts at the Ukrainian border. European Journal of Psychotraumatology, 13(2), Article 2101759. http://doi.org/10.1080/20008198.2022.2101759
Abstract:
Background: The ongoing horrors of the war in Ukraine have led to enormous consequences: loss of life, severe injuries, and mass movements of civilians. Exposure to war, living in conflict zones, and forced displacement increase the risk of experiencing a broad spectrum of direct and indirect burdens towards physical and mental health, in particular among children.
Objective: This letter to the editor aims to provide multiple clinical and ‘mental health and psychosocial support’ (MHPSS) systems’ perspectives by experts working in ongoing aid efforts to bridge and disseminate their current observations towards child and adolescent mental health services involved in the mental health response to the current war in Ukraine. Results and Discussion: The diverse perspectives from three mental health professionals involved in the MHPSS response highlight the different burdens and needs of children being confronted with situations of an existential nature. Children live through transformed social situations, deteriorated life conditions, general uncertainty, and encounter numerous losses. As such, war is the ultimate non-normative and existential stressor. The four perspectives highlight the need to: (1) adjust help toward the needs of the beneficiary, (2) understand help efforts as intersubjective human encounters and enable parents and caregivers in these encounters, (3) recognise losses and embrace finding ways to facilitate grief, and (4) continue to address these needs in a coordinated way that follows inter-agency guidelines.
Conclusion: Better understanding the needs of refugee children underlines the importance of investing in their future by providing resources for humanitarian aid and psychosocial interventions during sustained emergencies. The perspectives presented in this letter emphasise that psychosocial care is deeply rooted in intersubjective help-encounters and, therefore, a professionalisation of interventions should co-occur with their humanisation and be adapted to subjective needs, varying sociocultural backgrounds, and the individuals themselves with the goal of reducing suffering and fostering well-being.