Treating Adult Survivors of Childhood Emotional Abuse and Neglect: a New Framework

social innovations Treating Adult Survivors of Childhood Emotional Abuse and Neglect: A New Framework Frances K. Grossman Joseph Spinazzola and Marla Zucker The Trauma Center at Justice Resource Institute, The Trauma Center at Justice Resource Institute, Brookline, Massachusetts Brookline, Massachusetts, and Suffolk University Elizabeth Hopper The Trauma Center at Justice Resource Institute, Brookline, Massachusetts ver the past four decades, we of study participants with less complicated American Academy of Pediatrics produced have seen major advances in co-occurring clinical disorders, behavioral a policy report naming psychological mal- O mental health intervention for issues, and functional impairments than treatment as “the most challenging and prev- adults and more recently children affected those typically encountered in real-life clin- alent form of child abuse and neglect.” by exposure to traumatic events and experi- ical community practice settings. At our outpatient trauma-specialty clinic in ences. An impressive body of clinical re- This historic partial reliance upon un- Brookline, MA, we have grappled for decades search now supports the empirical evidence representative samples to validate tradi- with how to best serve adult (and child) sur- base for a number of psychotherapeutic tional treatment models raises important vivors of complex trauma, namely, prolonged treatment models for use with victims of questions about the generalizability of and recurrent exposure to maltreatment, ne- traumatic stress. However, despite the great these findings toward meeting the needs of glect, violence, and exploitation and the ensu- proliferation of approaches to the treatment adult trauma survivors suffering from ing complex effects these experiences have on of psychological trauma, the majority of more complex adaptation to trauma. This mental health and physical wellbeing, mal- these models and the research that supports concern has led prominent scholars and adaptive coping, engagement in risk behav- their effectiveness have been principally de- clinical researchers such as Marylene iors, and the derailment of normative life tra- signed to address symptoms of one specific Cloitre to challenge the adequacy of one- jectories leading to long-term health and psychiatric diagnosis, posttraumatic stress size-fits-all approaches to trauma treat- educational, relational, and occupational suc- disorder (PTSD). Although undoubtedly a ment, particularly when attempting to aid cess. At the forefront of this struggle has been pernicious and pervasive condition, epide- the recovery of adult clients with chronic, the challenge of adequately treating the clients miological research in adult and child pop- multilayered, and treatment-resistant psy- most often “in the shadows:” adult survivors ulations has clearly established that PTSD is chological and psychiatric conditions. of severe childhood emotional abuse and ne- neither the sole nor even most common con- Perhaps least represented in existing treat- glect. Despite nearly a half-century of atten- dition experienced by survivors in the after- ment outcome research are the needs of tion directed in psychiatry, psychology, social math of trauma. In fact, our own research adult survivors of childhood maltreatment work, and allied professions to the develop- has demonstrated that much of the extant experienced primarily in the form of severe ment of treatment models for victims of psy- clinical research supporting the evidence emotional abuse and neglect during child- chological trauma, resulting in the establish- base of traditional psychotherapy models for hood. Frequently overlooked, minimized, or ment of nearly 100 distinct evidence-based or promising practices, to date not a single one of treatment of PTSD and related disorders in misunderstood is psychological maltreat- This document is copyrighted by the American Psychological Association or one of its allied publishers. these models has been specifically designed to adults has been predicated upon recruitment ment, defined as children’s exposure to re- This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. current and severe forms of emotional abuse target the effects of childhood emotional abuse and emotional neglect including insults, and neglect in adult or (for that matter) child shaming, degradation, threats, shunning of survivors. Moreover, the vast majority of these Frances K. Grossman, The Trauma Center at affection, forced isolation, exploitation and models neglect to include even a single page Justice Resource Institute, Brookline, Massachu- imposition of excessive and unrealistic de- of specific guidelines or considerations for setts; Joseph Spinazzola and Marla Zucker, The mands. Psychological maltreatment has long working with this population. Trauma Center at Justice Resource Institute and been identified in large-scale research—in- In our research and that of our colleagues, Department of Psychology, Suffolk University; cluding the Centers for Disease Control’s we have amassed considerable evidence ver- Elizabeth Hopper, The Trauma Center at Justice ifying that victims of childhood emotional Resource Institute. seminal Adverse Childhood Experiences Correspondence concerning this article should be studies—as a major public health problem. abuse and neglect exhibit equal or worse addressed to Frances K. Grossman, Trauma Center Only recently, however, has it been recog- immediate and long-term effects than survi- at Justice Resource Institute, 1269 Beacon Street, nized as a major target of health disparities vors of other forms of maltreatment and Brookline, MA, 02446. E-mail: [email protected] research and policy. In fact, in 2012 the violence that have been much more the fo- American Journal of Orthopsychiatry © 2017 American Orthopsychiatric Association 2017, Vol. 87, No. 1, 86–93 http://dx.doi.org/10.1037/ort0000225 social innovations cus of clinical and research attention over central mission. In this spirit, we endeavored of multidisciplinary psychotherapists and al- the past four decades (e.g., physical abuse, to articulate a clinical framework for complex lied professionals locally and nationally. sexual abuse, community and domestic vio- trauma treatment intentionally designed to ad- CBP is an evidence-informed model that lence). Moreover, through this research we dress longstanding disparities in the mental bridges, synthesizes, and expands upon sev- have been able to demonstrate empirically health field by emphasizing the needs of this eral existing schools, or theories, of treatment for adult survivors of traumatic stress. These include approaches to therapy that stem from more classic traditions in psy- To date, no treatment model has been speciﬁcally chology, such as psychoanalysis, to more designed to target the effects of childhood emotional modern approaches including those informed by feminist thought. Moreover, CBP abuse and neglect places particular emphasis on integration of key concepts from evidence-based treatment models developed in the past few decades what we had long observed anecdotally in our chronically marginalized and misunderstood predicated upon thinking and research on clinic work, namely that these survivors ex- subpopulation of trauma survivors. the effects of traumatic stress and processes hibit overlapping but distinct outcomes, or We regard this emphasis upon social jus- of recovery for survivors. clinical profiles, compared with other survi- tice to be of particular importance for two vors of childhood trauma. For example, we reasons. First, we have come to view the found that victims of emotional abuse and heretofore often overlooked or minimized The Empirical Base for CBP neglect tend to have more widespread or backdrop of pronounced childhood emo- The overall structure and four compo- global effects across domains of self and iden- tional abuse and emotional neglect as an nents of CBP intentionally build directly tity, behavior and functioning, and clinical invisible web that binds and drives many of upon four empirical bases of evidence: (a) psychopathology. Specifically, these trauma our clients toward lifelong trajectories of the extensive clinical and research evidence survivors tend to show greater impairment in failure, revictimization, and self-loathing. base on the importance of processing trau- Second, we believe that authentic engage- the capacity to establish and maintain safe, matic memories and constructing a trauma ment in trauma-informed services necessi- healthy, and loving relationships; to possess narrative as an essential component of treat- tates that therapists educate and collaborate more negative self-image, worth, or esteem; to ment of traumatic stress; (b) the evolving with multidisciplinary professionals not be more likely to internalize their distress, awareness across disciplines of psychology only to recognize and appreciate the perva- leading to more frequent difficulties with de- and psychiatry that the quality of engage- sive reality and deleterious effects of child- pression, anxiety, social withdrawal, and iso- ment, empathic rapport, and authenticity in hood emotional abuse and neglect, but also lation; and to engage in more maladaptive the client–therapeutic relationship is integral to identify and challenge mental health prac- forms of coping, including greater prevalence to the treatment process; (c) the expert tices and societal structures that obfuscate or of self-injury,

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