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COUNSELING VICTIMS OF VIOLENCEA Handbook for Helping Professionals
By SANDRA L. BROWN
Hunter House Inc., PublishersCopyright © 2007 Sandra Brown
All right reserved.
Chapter OneA Victim's Story
THIS VICTIM'S STORY, as well as the many stories you have or will undoubtedly hear as a counselor, help us to see the complexity of victimization. Interwoven into victims' lives-whether male or female-are personal histories of trauma, mental-health challenges, financial obstacles, relationship problems, community services shortages, missed intervention opportunities, and an array of other mitigating circumstances that make their treatment complicated. Victims bring to our offices their plethora of tangled problems, which we must try to unravel with them.
As you read Ladonna' story, begin to imagine what your intervention strategies might be. What kinds of treatment issues do you think might arise in her case? What kinds of social and public services might a case like hers require? How could you as a counselor be most effective in a complex situation such as this? Although Ladonna's life situation is complex, so are those of many victims.
VICTIM'S STORY LADONNA Ladonna was one of what she referred to as "too many children" in her family. She wasraised in abject poverty and her father was in and out of employment while she was growing up. A grandmother lived with the family and helped with all the children and the chaos. Alcohol and poverty went hand-in-hand in this family, and both the adults and young adults had drinking problems. When Ladonna was a young girl, her grandmother began sexually abusing her. The grandmother was a matriarchal figure and highly respected in the family. Hints Ladonna gave to other adults about the abuse were ignored, and she was spanked for alleging that it had occurred. She continued to endure sexual abuse by her grandmother for years. In addition, at puberty, a male cousin began to rape her. Ladonna's school attendance became sporadic during these times of abuse, and her grades, which were once good, dropped dramatically. Teachers spoke to her about her obvious depression and the events of her home life, but no one pursued the problem-not even the school counselor to whom she was eventually referred. To Ladonna, safety meant escaping from the abusive environment in which rape, molestation, deprivation, and addiction were rampant. To flee, she married Larry, the first man who showed interest in her. He, too, had an undisclosed history of violence and addiction. However, Ladonna was too focused on escaping her own torture to ask many questions about his life and habits. She didn't know about his mounting criminal assault charges, drug dealing, and usage. She just knew he promised to take her out of her house and into his. And so she went. She married Larry at the age of fifteen and a half. It wasn't long before Ladonna found out that rape was also part of her new life, as were many of the things she thought she could escape-such as violence, addiction, and too many children. Practically before she knew it, Ladonna had six children, and the cycle of poverty and violence had been established in her own home. Each time she tried to leave the relationship, Larry threatened to kill her or one of the children. Ladonna's early childhood abuses had set up a pattern of low self-esteem and hopelessness. As a result, it didn't occur to Ladonna that anyone might be able to help her escape. No one had helped her when she was younger; no one responded to the obvious signs that something was wrong in her life. So she did not reach out beyond her biological family. And those in her family with whom she talked were not helpful because they shared the same hopelessness. Years of countless rapes and beatings left Ladonna wanting another way out, so she found a man who offered to help her escape. Just as in her youth, Ladonna felt any way out involved a man taking her from her miserable life into a promised life. Steve convinced her that Larry would only kill her, not the children. He said that if she escaped with him, she could come back later for her children. So Ladonna snuck off with Steve while Larry was at work, and she left her children behind. Steve took her to another city to "protect her" from Larry, but soon the cycle of violence and poverty began all over again. Steve was a heavy drug dealer and user. In order for him to maintain his drug habit, he needed Ladonna to "earn income" for him. So she started performing sex acts to enable Steve's drug addiction. Ladonna's thoughts about these sex acts mingled with flashbacks of her early childhood abuse and marital rapes and produced an imagery so powerful and disturbing she needed help to get through what she was doing. She, too, began to use drugs and alcohol. Steve continued to bait her by telling her that as soon as they saved enough money, they would get her children back. But the drugs ate up all their income, and the children never arrived. As both of their drug dependencies increased, the sex trade no longer provided an adequate income. One night, Steve convinced Ladonna to help him rob someone for drug money. The robbery did not go as planned, so Steve took the man into the alley and shot and killed him. Ladonna went to prison for second degree manslaughter. Despair ridden, Ladonna realized her children were as trapped as she was-destined to repeat her life as they lived out a rerun of her childhood. But more despair was just around the corner. While in prison, Ladonna was diagnosed with HIV. Somewhere between rapes, IV drug use, and sex trade work, she had contracted a life sentence. Considering her twelve-year prison sentence, would she live long enough to find real and lasting love? Another inmate told her she didn't have to wait. So Ladonna began a relationship with Shirley-another drug user and violent lover. For ten years, they were lovers in prison. Shirley, like Ladonna's previous men, controlled her every move. When Ladonna objected, Shirley beat her. Ladonna lived with the same fear she had felt since her grandmother began abusing her as a child. Shirley completed her prison sentence and was released. She found an apartment and began taking meager, low-paying jobs while she waited for Ladonna's release. When Ladonna was released, the only place she had to go was the apartment Shirley had established. Ladonna had long since lost contact with her family. She had not contacted her children in the twelve years since her prison term began. In fact, as far as she knew, her children were not even aware she had been in prison. Life on the outside with Shirley did not offer the "love" Ladonna had hoped to find. Both of them quickly lapsed into drug and alcohol abuse. As a result, Ladonna's immune system became dangerously depleted. She was losing ground in her battle against HIV. Because she had neither insurance nor money, she could not obtain treatment. Shirley continued to be violent with Ladonna. As her health failed, so did Shirley's tolerance. One day, during a beating, Ladonna stabbed Shirley and fled. It was a superficial wound, inflicted without forethought, but it served as a wake-up call for Ladonna. She didn't want anymore violence, especially not if it landed her back in prison, only to die there. Ladonna fled to a domestic-violence shelter, where she found sanctuary, sobriety, and support. Today, Ladonna has full-blown AIDS and lives in a case-managed AIDS group home. She has just located her children and wants to rebuild her relationship with them during the time she has remaining.
Ladonna's life offered many intervention opportunities for counselors. Most of these opportunities were missed by those few counselors she did encounter during her fifty-plus years. Elementary, middle, and high school counselors all failed to respond to the obvious clues in her life. Even in prison, no counselors asked what aspects of her experience had led her to such extremes. Other missed opportunities included the free clinics she might have visited while she was in the sex trade, as well as other health workers along the way who could have had a peek at her life and problems.
Ladonnas exist everywhere, with stories that span the decades of their tortured lives. Counseling Victims of Violence offers interventions that can bring hope to the Ladonnas who are praying you will help them. Will you have the skills necessary to help them in their recovery when they arrive at your office?
Chapter TwoThe Psychodynamics of Trauma
VICTIMIZATION OF ANY KIND leaves its fingerprints upon the soul of the victim. Clinical evidence has suggested that physical and psychological well-being of violent crime survivors are affected by their experiences of violence (Schiraldi 2000; Walker 1991). Therefore, a humanitarian response to the epidemic of violence in this country is to provide trained counselors who are equipped with the tools needed to defuse the victims' symptoms and reduce their psychic injuries.
To do this, we must understand trauma and its effects. We need a practical approach to assessing the damage done by trauma. Because not all victims respond in the same ways to trauma-even when they experience the exact same types of trauma-a clinician must know how to assess their experiences of victimization. Before we can actually begin to assess the victims, we must understand the types of trauma disorders and stress reactions that victimization can produce.
We look first at an overview of trauma-related disorders and then in greater detail at the most prevalent reaction to trauma: posttraumatic stress disorder. The chapter concludes with sections about the psychobiology of trauma disorders, secondary victimization, the grief process, and theoretical approaches to treatment.
Victims who have experienced a perceived life-threatening event, numerous adult traumas, or reoccurring abuse as a child can exhibit a range of mental-health disorders. The field of victimology, which has been recognized for a couple of decades, offers insight into these disorders. The disorders themselves are merely starting points from which to look for symptoms commonly associated with similar traumas. However, it is important that each victimization case be considered individually. Individual diagnosis and resulting outcomes can be affected by the following factors:
* Ego strength
* Victimization history
* Previous mental-health disorders
* Coping style
The disorders described below are often associated with traumatic coping responses. Although we are used to thinking of them as "disorders," I suggest you also think of them as "responses" to violence and trauma. Doing so can help you see the coping response within each disorder, and understand why the etiology was developed in terms of the traumatic response. (For more information about any of these disorders, please consult the Diagnostic and Statistical Manual of Mental Disorders IV.)
Mood disorders are often related to traumatic exposure (Hulme 2000; McCauley et al. 1997; Jumper 1995; Briere 1992). One common reaction to trauma is depression. This can occur immediately following the event. If treatment is not provided, the victim can acquire a mood disorder at a later time. Emotional withdrawal, often seen as depression, is one common coping style following an act of violence.
Addiction is often a medicating reaction that is related to an untreated mood disorder or depression. We now know that not treating crime victims' emotional wounds can result in substance-related issues if the victim uses drugs as an inappropriate coping mechanism. Many victims self-medicate, but not all go on to develop substance abuse disorders. The counselor should not only look for the symptoms of full addiction, but should be on the look out for any maladaptive use of a substance. Early intervention can prevent addiction.
NARCISSISTIC PERSONALITY DISORDER (NPD)
NPD is often related to childhood neglect, abuse, or trauma. However, there are some exceptions, and a reverse relationship does not exist. Single-incident victimizations experienced by adults do not normally produce NPD. Any personality disorder diagnosis should, at the least, serve as a red sag for potential early childhood abuse or neglect. In the case of a personality disorder, the victim's childhood should be intensely examined (with the use of an appropriate assessment tool) for neglect, abuse, or trauma. Narcissism, as a coping response, appears as an intense self-focusing reaction. Early childhood trauma exposes the child to feelings of "no self-focus" by the abusing or neglecting caregivers. The child's needs are grossly ignored and unmet. What seems to be an over-inflated ego in narcissism is really the absence of a self-construct that should have developed during the period when the child was neglected or abused.
POSTTRAUMATIC STRESS DISORDER (PTSD)
The extent to which a person experiences PTSD is related to the nature of previous childhood traumas and/or the intensity of trauma experienced as an adult. The more trauma a person has experienced, the stronger the PTSD reactions can be. The features most associated with PTSD include numbing and hyperarousal, both of which are sources of coping. Numbing helps the person distance from the overwhelming affect associated with the trauma. Hyperarousal gives the victim a sense of acute awareness that feels like "safety." (Because PTSD is the most prevalent reaction to intense trauma, it is covered in more detail below.)
BORDERLINE PERSONALITY DISORDER (BPD)
Much like NPD (discussed above), any personality disorder diagnosis should alert the counselor to use an appropriate assessment tool to identify possible early childhood trauma or neglect. Borderline personality disorder, in particular, is a noteworthy diagnosis that is frequently associated with early onset neglect, abuse, or trauma (Cole and Putnam 1992). The particular features of this disorder point to maladaptive coping attempts, such as frantic efforts to avoid abandonment, over- or under-idealizing and devaluing others, self-damaging impulsivity, suicidal behavior, intense anger, and emotional instability. This diagnosis can complicate a treatment regime, which can be as problematic for the counselor as it is for the patient.
OBSESSIVE-COMPULSIVE DISORDER (OCD)
OCD falls within the category of anxiety disorders. Trauma-whether early onset or mixed with adult traumas-can result in OCD behaviors. The victim attempts to use repetitious thoughts or behaviors as a coping response to neutralize the intensity of the traumatic memory.
Dissociative disorders represent the most complicated and severe reaction to trauma. These disorders are noted for their amnesic and fragmenting qualities. They operate as resistance to the trauma by disconnecting the event from memory. This is a highly developed coping mechanism for unassimilated and overwhelming trauma (Putnam and Trickett 1993; Briere 1992; Cole and Putnam 1992; Summit 1983) and requires intense intervention for the assimilation of the traumatic memories. The presence of a dissociative disorder warrants ruling out early childhood, long-term abuse because many victims acquire this disorder from those types of experiences. Additionally, many persons with dissociative disorders also have some of the other disorders listed here as trauma disorders.
Many dissociative disorders are acquired as an ultimate attempt to cope with ongoing and unrelenting victimization. Some dissociative disorders can be experienced as adult onset, especially following a major disaster. A counselor should know the difference between child-onset and adult-onset dissociative disorders. Additionally, many counselors find themselves inadequately trained to treat difficult cases of dissociative disorders. If you have not been trained, you should seek supervision through the treatment process.
Some specialists in the field of victimology add the following disorders to the list of trauma disorders. We will not discuss these disorders in detail, but readers may want to familiarize themselves with them.
* Conversion disorder
* Somatoform disorder
* Acute stress disorder (a precursor to PTSD)
Excerpted from COUNSELING VICTIMS OF VIOLENCE by SANDRA L. BROWN Copyright © 2007 by Sandra Brown. Excerpted by permission.
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