As noted early in this guide, survivors of early and severe childhood trauma or neglect often complain of problems associated with an inability to access, and gain from, an internal sense of self.
This may present, for example, as (1) problems in determining one’s own needs or entitlements, (2) maintaining a consistent sense of self or identity in the context of strong emotions or compelling others, and (3) having direct access to a positive sense of self when external conditions or people are challenging or negative.
Many of these difficulties are thought to develop in the early years of life, when the parent-child attachment relationship is disrupted by caretaker aggression or neglect (Bowlby, 1988). In addition to possible negative impacts on the developing child’s psychobiology (Pynoos, Steinberg, & Piacentini, 1999; Schore, 2003), childhood abuse and neglect can motivate the development of adaptations and defenses that, in turn, reduce the child’s development of a coherent sense of self (Briere & Rickards, 2007; Elliott, 1994).
Probable etiologies for identity disturbance include early dissociation, other-directedness, and the absence of benign interactions with others (Briere, 2002). Dissociating or otherwise avoiding trauma-related distress early in life may block the survivor’s awareness of his or her internal state at the very time that a sense of self is thought to develop in children. Further, the hypervigilance needed by the endangered child in order to ensure survival means that much of his or her attention is directed outward, a process that detracts from internal awareness. When introspection occurs, it is likely to be punished, since (a) such inward focus takes attention away from the environment and, therefore, increases danger, and (b) greater internal awareness means – in the context of ongoing trauma – greater emotional distress (Briere & Scott, 2012). Finally, most theories of self-capacities stress the role of benign others in the child’s development – one may have to interact with caring others in order to form a coherent and positive sense of oneself (e.g., Stern, 2000). This is thought to occur when the loving and attuned caretaker reflects back to the child what the child appears to be feeling or experiencing, responds to the child’s needs in a way that reinforces their legitimacy, and treats the child in such a manner that he or she can infer positive self-characteristics. As the child develops into an adolescent, the growing complexity of his or her interactions with the social environment ideally bestows a growing sense of self in the context of others. Unfortunately, this progression into an increasingly coherent identity may be less possible for those who were deprived of positive parenting. Self/identity issues are often exacerbated in adolescence, when many young people – abused or otherwise – experience significant tumult as their sense of identity undergoes significant change. In this context, adolescents with abuse-related difficulties may especially suffer.
Because much of self-development appears to involve interactions with caring others, the therapeutic relationship can be a powerful source of stimuli and support for the client’s growing sense of self. In this context, the clinician may work to accomplish several tasks.
Provide Relational Safety
Introspection is, ultimately, a luxury that can only occur when the external environment does not especially require hypervigilance. For this reason, the clinical setting should provide those aspects of safety outlined previously in this treatment guide. Not only should the client feel physically safe, he or she should experience psychological safety – the clinician should be psychologically noninvasive, consistently supportive and psychologically available, careful to honor the client’s boundaries, and reliable enough to communicate stability and security. When these conditions are met, the youth is more likely to trust the interpersonal environment enough to explore his or her internal thoughts, feelings, and experiences.
The process of discovering that one is actually safe in treatment, however, may be protracted – many survivors of severe childhood or adolescent trauma, for example, “street kids,” adolescents caught in the sex trade, and others exposed to years of victimization, may have to be in treatment for some time before they can accurately perceive the safety inherent in the session (see the discussion of disparity in Chapter 10). Similarly, as described in Chapter 13, characteristics of the therapist (e.g., older age, gender, role as an authority figure) or the therapy (e.g., seeming demands for emotional intimacy or vulnerability) may trigger memories of abuse that must be addressed to some extent before the adolescent can accurately perceive an absence of danger in the therapy session. Even then, this sense of relative safety may wax and wane.
Also helpful is the therapist’s visible acceptance of the adolescent’s needs and perceptions as intrinsically valid, and his or her communication to the client regarding the client’s basic relational entitlements, per Chapter 5. To some extent, this may appear to contradict the need to challenge the client’s negative self-perceptions and other cognitive distortions. However, the approach advocated in this guide is not to argue with the client regarding his or her thinking errors about self, but rather to work with the client in such a way that the he or she is able to perceive incorrect assumptions and reconsider them in light of his or her current (therapy-based) relational experience. For example, even though the adolescent may view himself or herself as not having rights to self-determination, these self-perceptions will be contrary to the feelings of acceptance and positive regard experienced in the therapeutic session. Such cognitions, when not reinforced by the clinician, are likely to decrease over time. Equally important, as the message of self-as-valid is repeatedly communicated to the client by the therapist’s behavior, client notions of unacceptability are relationally contradicted, especially in the context of therapist caring.
This general focus on the client’s entitlements can help to reverse the other-directness the survivor learned in the context of abuse or neglect. During most childhood abuse, attention is typically focused on the abuser’s needs, the likelihood that he or she will be violent, and, ultimately, on the abuser’s view of reality. In such a context, the child’s needs or reality may appear irrelevant, if not dangerous when asserted. In a safe, client-focused environment, however, reality becomes more what the client needs or perceives than what the therapist demands or expects. When the focus is on the client’s needs, as opposed to the therapist’s, the youth is often more able to identify internal states, perceptions, and needs, and discover how to “hang on to” these aspects of self even when in the presence of meaningful others (i.e., the therapist). By acting in such a way that it becomes clear to the adolescent that his or her experience is the ultimate focus, and by helping the client to identify, label, and accept his or her internal feelings and needs, the therapist helps the client to build a coherent and less negative model of self – to some extent in the way parents would have, had the client’s childhood been more safe, attuned, and supportive.
Support self-actualization versus social devaluation
In many cases, it may be important to encourage discussion of the youth’s beliefs, experiences, and perceptions regarding gender, race, cultural background, sexual orientation, gender identity, and other sociocultural issues. These discussions ideally reinforce the client’s self-determination and work against cultural stereotyping or discrimination. The process of discerning who one is in the social matrix, and how one should relate to culturally-based expectations, may not always be straightforward. For example, although the adolescent may have the appearance of a specific culture/ethnic background, he or she may identify with another culture or may have a sense of belonging in more than one culture if he or she has a mixed racial/cultural background. Gay, lesbian, or transgendered youth may have conflicting experiences of self, reflecting socially-transmitted messages about the unacceptability of any sexual orientation not classically heterosexual. They may have undergone years of socialization to view “normal” sexuality as involving attraction to members of the opposite-sex based on their biological gender, and to assume that relational success is heterosexual marriage and the bearing of children. Similarly, youth whose ethnicity has been regularly devalued by Anglo-American culture, whether based on skin color or cultural background, may have internalized what are essentially self-hating perspectives. In all these cases, the culturally-aware clinician can work with the youth to develop self-perceptions that are positive and empowering, generally through cognitive reconsideration of injurious or invalidating assumptions.
As therapy facilitates self-exploration and self-reference (as opposed to defining self primarily in terms of others’ expectations or reactions), the abused youth may be able to gain a greater sense of his or her internal topography. Increased self-awareness may be fostered particularly when the client is repeatedly asked about his or her on-going internal experience throughout the course of treatment. This may include (as described in at various points in this guide) multiple, gentle inquiries about the client’s early perceptions and experiences, his or her feelings and reactions during and after victimization experiences, and what his or her thoughts and conclusions are regarding the ongoing process of treatment. Equally important is the need for the client to discover, quite literally, what he or she thinks and feels about current things, both trauma-related and otherwise. Because the external-directedness necessary to survive victimization generally works against self-understanding and identity, the survivor should be encouraged to explore his or her own general likes and dislikes, views regarding self and others, entitlements and obligations, and related phenomena in the context of therapeutic support and acceptance. As noted early in this guide, this exploration may be facilitated when the clinician conveys actual interest and curiosity about the client’s internal states and processes.
The therapist’s consistent and ongoing support for introspection, self-exploration, and self-identification allows the abused adolescent to develop a more articulated and accessible internal sense of self, and a stronger sense of self-efficacy. Ultimately, the therapist takes on the role of the supportive, engaged, helpful figure whose primary interest – beyond symptom resolution – is the development of the adolescent’s internal life and self-determinism. This process, although less anchored in specific therapeutic techniques or protocols, can be one of the more important aspects of treatment.