Benefits of a Contextual Approach to Understanding and Treating Complex Trauma

Abstract

The conceptual framework and treatment rationale of contextual therapy are described. Contextual therapy was specifically fashioned for survivors of prolonged child abuse (PCA). It is grounded in the observation that contexts beyond abuse trauma, especially restrictions in psychological development stemming from growing up in an ineffective family environment, appreciably impact the adjustment of many PCA survivors. Contextual therapy proposes that remediation of developmental gaps commonly manifested by PCA survivors is essential to equip them to (a) benefit from rather than be debilitated by trauma processing and (b) move beyond symptom reduction to the attainment of adequate social and occupational functioning.

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Benefits of a Contextual Approach to Understanding and Treating
Complex Trauma
Steven N. Golda
a Trauma Resolution & Integration Program, Nova Southeastern University,
To cite this Article Gold, Steven N.(2008) 'Benefits of a Contextual Approach to Understanding and Treating Complex
Trauma', Journal of Trauma & Dissociation, 9: 2, 269 — 292
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Journal of Trauma & Dissociation, Vol. 9(2) 2008
Available online at http://jtd.haworthpress.com
© 2008 by The Haworth Press. All rights reserved.
doi:10.1080/15299730802048819 269
WJTD1529-97321529-9740Journal of Trauma & Dissociation, Vol. 9, No. 2, Apr 2008: pp. 0–0Journal of Trauma & Dissociation Benefits of a Contextual Approach
to Understanding and Treating
Complex Trauma
Steven N. GoldJournal Of Trauma & Dissociation Steven N. Gold, PhD
ABSTRACT. The conceptual framework and treatment rationale of
contextual therapy are described. Contextual therapy was specifically
fashioned for survivors of prolonged child abuse (PCA). It is grounded in
the observation that contexts beyond abuse trauma, especially restrictions
in psychological development stemming from growing up in an ineffective
family environment, appreciably impact the adjustment of many PCA
survivors. Contextual therapy proposes that remediation of developmental
gaps commonly manifested by PCA survivors is essential to equip them
to (a) benefit from rather than be debilitated by trauma processing and
(b) move beyond symptom reduction to the attainment of adequate social
and occupational functioning.
KEYWORDS. Child abuse, trauma, psychotherapy, contextual therapy,
family environment
The purpose of this article is to present the core theoretical framework
and describe the general treatment rationale of contextual therapy.
Detailed accounts of the particular intervention strategies that follow from
Steven N. Gold is affiliated with the Trauma Resolution & Integration
Program, Nova Southeastern University.
Address correspondence to: Steven N. Gold, PhD, Center for Psychological
Studies, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale,
FL 33314 (E-mail: gold@nova.edu).
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270 JOURNAL OF TRAUMA & DISSOCIATION
this model have been delineated elsewhere (e.g., Gold, 2000, in press;
Gold et al., 2001; Gold & Seifer, 2002). The aim here is to provide an
extensive description of the conceptual formulation that informs contextual
treatment.
Contextual therapy is a treatment approach that was specifically fash-
ioned for survivors of prolonged child abuse (PCA). It is grounded in the
recognition that contexts and factors beside explicit episodes of abuse
trauma play a major role in shaping the adjustment of PCA survivors and
other forms of complex trauma. In brief, contextual therapy grew out of
the observation that PCA survivors manifest a wide range of difficulties
beyond symptoms associated with posttraumatic stress disorder (PTSD)
and other trauma-related syndromes. They often display major limitations
in fundamental areas of adult adaptation such as the ability to maintain
employment and be financially independent, the capacity for relating
intimately and sustaining enduring friendships, and establishing structure
and continuity in their lives. These difficulties do not seem to be entirely
attributable to their trauma-related symptomatology; they persist even
after PTSD and other trauma-related symptoms have subsided. The nature
of these difficulties themselves and the reports of PCA survivors about
their personal and family histories suggest that the difficulties reflect gaps
in development stemming from having grown up in family and social
environments that did not adequately prepare the survivors for adult
living. Contextual therapy builds on the assumption that these develop-
mental, familial, and social contexts must complement the context of
trauma in order to intervene efficiently and effectively with this clinical
population.
THE CONCEPTUAL AND EMPIRICAL FOUNDATION
OF CONTEXTUAL THERAPY
The Trauma Context and Beyond
The relationship of trauma to a wide range of psychological as well as
medical problems is documented by an extensive and continually expanding
body of empirical research (Anda et al., 2006; Gold, 2004). Frequently
clinicians find that the relevance of psychological trauma to a substantial
proportion of cases encountered in general clinical practice becomes
immediately obvious once they become familiar with the knowledge base
on trauma and its psychological impact. For many of these practitioners,
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Steven N. Gold 271
learning about trauma and its crucial contribution to the difficulties of a
substantial proportion of psychotherapy clients is experienced as opening
up new vistas of discernment. In situations where others may only see
incomprehensibly bizarre and disproportionate reactions to current
circumstances, mental health professionals knowledgeable about trauma
recognize the possibility that a history of traumatic experiences can
render these behaviors understandable. As a result, awareness of trauma,
its impact, and methods for helping people resolve traumatic experiences
so that they are no longer plagued by their aftermath arms practitioners
with an invaluable set of clinical resources.
In this manner trauma provides an essential context for making sense
of a large range of clinical phenomena that would otherwise seem inexpli-
cable. And yet all too often, it seems as if the discovery of the role of
trauma in the difficulties of many clients blinds practitioners to much of
what they already knew about other potential influences on adjustment.
There is no question that the adverse impact of trauma on psychological
functioning can be rapid, extensive, and profound. Preoccupation with the
role of trauma in accounting for client difficulties, however, can become
so salient that it interferes with awareness of other contexts that can be
just as essential to clinical understanding. When a practitioner loses sight
of the importance of these other contexts beyond trauma, therapeutic
effectiveness, even with those clients who do have an extensive trauma
history, can be radically diminished.
The Family Environment and Developmental Contexts
Appreciating the roles of family environment, other social influences,
and developmental trajectory is especially crucial when working with
survivors of complex trauma. Empirical findings and clinical observation
both suggest that PCA is by far the most commonly encountered type of
complex trauma (Herman, 1992a; Roth, Newman, Pelcovitz, van der Kolk, &
Mandel, 1997). Overt instances of abuse among PCA survivors almost
inevitably occur in concert with being reared in a distant, inconsistent,
ineffective family environment that fails to adequately foster psychological
development (Gold, 2000). Vincent Felitti (2002), one of the lead investi-
gators on a series of research studies investigating a constellation of eight
central “adverse childhood experiences” on adult psychological and medical
well-being, has stressed the importance of this observation. In explaining
why he and his coinvestigators feel it is important that the abusive and
otherwise harmful childhood experiences they study be examined together
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272 JOURNAL OF TRAUMA & DISSOCIATION
rather than individually, he emphasized that abuse and other adverse
childhood experiences “do not occur in isolation; for instance, a child
does not grow up with an alcoholic parent or with domestic violence in an
otherwise well-functioning household” (p. 361).
Extensive empirical support for this statement can be found in research
by Felitti and his colleagues (e.g., Dong, Anda, Dube, Giles, & Felitti,
2003; Dong et al., 2004). They have repeatedly found that child abuse is
related to a wide range of indicators of household dysfunction. Further-
more, studies document that beyond the particular co-occurring adverse
childhood experiences examined by this research team, the general inter-
personal atmosphere in the families of origin of survivors of PCA differs
from that of families of normative groups in very specific ways. The
families of PCA survivors are characterized by extremely low levels of
cohesion, emotional expressiveness, and encouragement of independence,
and by very high degrees of control and interpersonal conflict (Gold,
Hyman, & Andres, 2004; Ray & Jackson, 1994). Factors such as low
levels of parental affection and high degrees of parental control have been
shown to be related to levels of maladjustment among child abuse survivors
(Finzi-Dottan & Karu, 2006). The descriptions heard clinically from this
group that correspond to these findings are of having been reared in families
that were distant, inattentive, or unpredictable in their responsiveness
and that therefore failed to provide sufficient and consistent emotional
nurturance, practical guidance, or transmission of the resources and skills
needed to reach adulthood equipped for effective daily living (Gold,
2000, 2001; Gold et al., 2001).
Investigations such as the adverse childhood experiences research can
readily be misinterpreted as merely indicating that a family environment
that exposes a child to certain types of maltreatment or adverse conditions
is likely to exhibit other negative characteristics as well. Similarly, it
would be easy to assume that the empirical studies showing a pattern of
low cohesion, emotional expressiveness, encouragement of independence,
and high conflict and control among the families of origin of PCA survivors
are simply identifying a configuration of characteristics emblematic of
abusive families. However, the distinctive constellation of traits detected
by these studies is in fact not unique to survivors abused by family members.
Essentially the same configuration of family characteristics is reported by
survivors of childhood sexual abuse, for example, regardless of whether
their molestation was committed by a family member or by someone
outside the family, or whether they were sexually assaulted during child-
hood and adolescence by several perpetrators, some familial and some
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Steven N. Gold 273
nonfamilial (Gold et al., 2004; Ray & Jackson, 1994; Ray, Jackson, &
Townsley, 1991; Yama, Tovey, & Fogas, 1993). This finding provides
compelling evidence that this pattern is not that of an abusive family per
se but of the type of family that renders a child vulnerable to abuse even if
it is by an extrafamilial perpetrator. Although these studies are based
on retrospective reports of child abuse survivors about their families of
origin, they are corroborated by overlapping accounts by abusive parents
themselves; when compared with nonabusive parents, parents who maltreated
their children described their families as lower in cohesion and less prone
to promote independence (Justice & Calvert, 1990).
Family Environment and Vulnerability to Abuse
Consider the characteristics described above that research indicates typify
the family environment in which PCA survivors are reared (Finzi-Dottan &
Karu, 2006; Gold et al., 2004; Long & Jackson, 1991; Ray & Jackson,
1994; Ray et al., 1991; Yama et al., 1993). There is little consistent affection,
validation, or emotional support. There is little predictability and
consistency. Rules are minimally existent or change precipitously based
on the whims of the parents and others in authority. There is a high degree
of control and a low level of encouragement of autonomy. What type of
child is this interpersonal setting likely to produce? One who is eager for
attention and affection; who lacks a sense of reasonable or appropriate
interpersonal boundaries; who is insecure and unassertive; and who
therefore is eminently vulnerable, compliant, and easily manipulated.
Research confirms that it is children such as this that pedophiles purposefully
seek out (Conte, Wolfe, & Smith, 1989; Lang & Frenzel, 1988).
This is consistent with the findings of several investigators that a
disrupted family environment is a major risk factor for child abuse
(Benedict & Zautra, 1993; Higgins & McCabe, 2000b; Mollerstrom,
Patchner, & Milner, 1992). Higgins and McCabe (2000a) found that
family cohesion and adaptability were inversely related to the number
of different types of maltreatment experienced in childhood. They also
concluded that family characteristics were also predictive of adjust-
ment to abuse. Similarly, Long and Jackson (1991) indicated that, as
compared to childhood sexual abuse survivors with one perpetrator,
those reporting multiple perpetrators described the families they grew
up in as lower in cohesion and expressiveness and higher in conflict
and control—the same traits that seem to characterize families whose
children are at increased risk for abuse.
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274 JOURNAL OF TRAUMA & DISSOCIATION
Children who grow up in the type of atmosphere documented in the
research literature—with inadequate emotional support and cohesiveness
or encouragement of independence—exhibit the traits that perpetrators of
interpersonal violence actively look for in prospective victims. They are
easily drawn in; easily manipulated; easily overpowered; and unlikely to
resist, protest, escape, or seek redress. They are at extreme risk for abuse
because perpetrators can readily recognize that they can be overpowered.
Rather than fighting back or becoming angry when aggressed against,
they are likely to be passively compliant and blame themselves for their
victimization.
Family Environment and Psychological Adjustment
One would presume that growing up in this type of family environment
would have severe adverse developmental consequences for children.
Although trauma theorists certainly recognize that the developmental
trajectory of PCA survivors deviates appreciably from the norm, they
commonly presuppose that developmental divergences manifested by
survivors are directly attributable to the effects of abuse trauma per se.
This premise is reflected in the recently proposed diagnostic category of
developmental trauma disorder (DTD; Deangelis, 2007). van der Kolk
(2005), for example, provided the following rationale for the diagnosis:
Isolated traumatic incidents tend to produce discrete conditioned
behavioral and biological responses to reminders of trauma, such as
those captured in the posttraumatic stress disorder (PTSD) diagnosis.
In contrast, chronic maltreatment or inevitable repeated traumatizations,
such as occurs in children who are exposed to repeated medical or
surgical procedures, have a pervasive effects [sic] on the development
of mind and brain. (p. 402)
The contextual model presented here differs in a subtle but decisive
way from the perspective espoused by van der Kolk and others. It posits
that development in PCA survivors is adversely affected not just by
chronic maltreatment, repeated abuse, or other forms of repeated trauma-
tization, but by having grown up in families that were not equipped to
adequately attend to survivors’ developmental needs. The absence in
these families of sufficient emotional support, mirroring and validation,
guidance and modeling, and structure and consistency hamper a wide
range of strands of development including secure attachment, stable and
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Steven N. Gold 275
positive self-esteem, affect regulation and impulse control, cognitive
reasoning and judgment, and the acquisition of various daily living skills.
Studies have repeatedly confirmed that family background contributes
to maladjustment in survivors over and above the influence attributable to
abuse (Fassler, Amodeo, Griffin, Clay, & Ellis, 2005; Higgins &
McCabe, 2000b, 2003; Nash, Hulsey, Sexton, Harralson, & Lambert,
1993; Ray & Jackson, 1997; Weaver & Clum, 1993; Yama et al., 1993).
In a study of adolescents reporting physical abuse, sexual abuse, or both,
heightened levels of family conflict and reduced levels of family cohesion
were predictive of depression and distress (Meyerson, Long, Miranda, &
Marx, 2002). Narang and Contreras (2005) identified that abuse history
was related to increased dissociation when respondents described their
families of origin as high in conflict, low in expressiveness, and low in
cohesion. Hanson, Lipovsky, and Saunders (1994) found that incestuous
fathers who indicated that they themselves had a history of childhood
sexual abuse (CSA) endorsed a more chaotic family history than incestu-
ous fathers who were not CSA survivors.
Distinguishing the Respective Influences of Family
Environment and of Trauma
How does this conception differ from that underlying the DTD
construct? Are these types of ineffective family functioning simply
neglect, child maltreatment, or abuse masquerading under another term?
What differentiates them from trauma?
There are several answers to these interrelated questions. A crucial one
is that many of the factors that commonly characterize the histories of
PCA survivors and that compromise or prevent normative developmental
attainments from occurring simply do not constitute trauma—whether
circumscribed, ongoing, or repeated. Although the absence of resources
that are required for normative development is unquestionably psycholog-
ically damaging, this does not necessarily mean that it is traumatic. This
is a point that can arouse intense emotional reactions among trauma
experts. For many professionals who specialize in trauma, and especially
in the maltreatment of children, to assert that unmet fundamental develop-
mental needs such as those for secure attachment, emotional validation, or
cognitive stimulation is not traumatic appears belittling or minimizing.
Suggesting that these factors do not constitute trauma is not to negate
that they may be intensely disturbing or that they can have extremely
catastrophic effects on the child. Nevertheless, the term trauma, like any
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276 JOURNAL OF TRAUMA & DISSOCIATION
psychological construct, is only meaningful if it is precisely defined and
delimited. Although there may be controversy about what the bounds of
the definition of trauma should be, there is a certain level of consensus
that (a) trauma consists of exposure to certain types of events, rather than
the lack or absence of certain types of events; and (b) these events do not
include all possible occurrences that are experienced as distressing or that
cause harm.
The closest approximation of a consensus definition of trauma is that
found in criterion A of the Diagnostic and Statistical Manual of Mental
Disorders (4th ed., text rev.; American Psychiatric Association, 2000)
diagnostic criteria for diagnosing PTSD (Weathers & Keane, 2007).
Although it could be argued that this definition of trauma is overly restrictive,
it limits traumatic events to those that entail “actual or threatened death or
serious physical injury, or a threat to the physical integrity of self or others”
(p. 467). The failure of parents to respond to the developmental needs of
their children does not even remotely fall within the parameters of this
definition of trauma.
Just as there are many factors other than trauma that can create psycho-
pathology, there are many factors other than trauma that can disrupt
normative development. A central point of contextual theory is not only that
forces besides trauma that can impair development exist, but that many
such factors are highly likely if not inevitably present in the histories of
people who grew up being subjected to protracted or repeated abuse trauma.
This is what the research on the family environments of abuse survivors
suggests. It is also the point Felitti (2002) was making when he observed
that adverse childhood experiences such as repeated or ongoing abuse
almost inevitably occur in families that are deficient in many other respects.
Distinguishing Ineffective Family Environments from Neglect
Although child neglect is often thought of as (and in most, if not all,
instances probably is) traumatic, the types of parenting failures identified
as routinely occurring in the histories of PCA survivors extend well
beyond what is commonly considered neglect. As the U.S. Department of
Justice, Office of Juvenile Justice and Delinquency Prevention (Handsnet,
1997) noted
the cornerstone of neglect is the concept of parental duty. Parents
have duties because, until many years after birth, the offspring of
our species cannot look after their own basic biological needs and
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Steven N. Gold 277
survival. . . . From a practical standpoint, a parent fulfills this duty by
doing certain things that promote growth, safety, and health. . . . [How-
ever] for various reasons, parents cannot always promote growth,
health, and safety to an optimal level, either because of their own limi-
tations, some restraint on them by their environment, or other reasons.
Also, not all harm is predictable or preventable. Therefore, parents
must not be held to a standard of perfect care. When the parental care
falls below a reasonable or prudent level, the child may be neglected.
(www.casanet.org/library/abuse/munchausen.htm)
In many instances the lapses in the family environments of PCA survivors
fall into this extensive gap between neglect and optimal parenting.
Although they fall short of adequately meeting the developmental needs
of the child, they are not so blatant, intentional, or extreme as to be considered
neglect. Often, the failure to fulfill the child’s needs is a reflection of
ignorance or inadequate development and learning in the parents them-
selves; they do not sufficiently provide for the child’s psychological
needs because they lack the knowledge or skills to recognize and effec-
tively respond to them.
TREATMENT IMPLICATIONS
The Need for Different Intervention Strategies
Perhaps the most important distinction between the impact of PCA and
that of being reared in an ineffective family environment, however, is a
practical one: The difficulties stemming from having grown up in a defi-
cient family environment require decidedly different intervention strategies
than those attributable to abuse or other forms of trauma. One reason why
it is easy to confound the impact of trauma with the effects of a family
environment that fails to adequately respond to the developmental needs
of its offspring is that these two factors can result in outcomes that essen-
tially appear to be identical. Both the trauma of being abused and growing
up in an invalidating and unpredictable family environment, for instance,
can lead to pervasive mistrust of other people. Analogously, both the
trauma of severe ongoing verbal abuse in childhood and the ongoing
experience of being unloved and uncared for by one’s parents can lead to
a profoundly negative self-image and low self-esteem. If the end result is
essentially the same, one may ask, what is the practical importance of
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278 JOURNAL OF TRAUMA & DISSOCIATION
such a distinction? Is there any reason why treatment for PCA survivors
needs to differ from that of survivors of any other form of trauma? If therapy
for PCA survivors of abuse needs to diverge from standard trauma
treatment, in what ways should it differ?
It was questions such as these that guided the development of contextual
therapy. It is an approach to treating PCA survivors that explicitly integrates
awareness of how the contexts of family of origin environment, societal
influences and assumptions, and developmental forces interact to exacerbate,
moderate, and otherwise shape the impact of trauma on adaptive functioning.
A contextual model is of tremendous practical importance in guiding
treatment for PCA survivors and other clients with a complex trauma
history. It also has the potential to provide clarification for a number of
theoretical questions that are difficult to answer satisfactorily from the
context of trauma alone.
Differential Treatment for PTSD and Complex PTSD
Succinctly stated, contextual therapy proposes that effectively treating
the difficulties of survivors of prolonged, repeated, and complex trauma
requires recognizing contributions to their problems in functioning
beyond trauma itself. From a standard trauma theory perspective, single-
event or circumscribed trauma results in PTSD, and prolonged or repeated
trauma leads to complex PTSD (Herman, 1992a, 1992b). This fairly
straightforward formula has led many clinicians to conclude that the same
basic therapeutic approaches that are effective for PTSD—ones in which
treatment pivots around uncovering, processing, and systematic exposure
to or desensitization to traumatic material—are just as appropriate for the
treatment of complex PTSD.
However, when one gathers a comprehensive history of survivors of
repeated trauma—especially of PCA survivors, a group of clients very fre-
quently encountered in general outpatient treatment settings—other consider-
ations become apparent. In the standard PTSD presentation, the client’s
functioning before encountering a circumscribed or single-event trauma is
relatively good. These clients usually report consistent employment and a
stable relationship history with no pronounced psychological difficulties
preceding the traumatic event. They describe a relatively stable family
background and a developmental trajectory that deviates minimally from the
norm, or in some cases may reflect superior functioning in one or more areas.
In stark contrast, the vast majority of clients presenting with a clinical
picture of complex PTSD describe a history in which a stable life structure
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Steven N. Gold 279
was never attained. They may lack understanding and skills for some
of the most rudimentary facets of adult adjustment, such as the need for
adequate sleep on a fairly regular schedule, the importance of nutrition
and fairly consistent mealtimes, and the necessity to master the elements
of physical and psychological self-care (see, e.g., Rabinovitch, 2003).
Their work history is often erratic. In the most extreme cases they have
never been able to sustain employment long enough to be financially
independent of either family or government support. Their relationship
history is even more frequently chaotic than their occupational history.
Beyond these general indices of adjustment, clients with complex PTSD
often reveal a background riddled with a host of ongoing or episodic
“comorbid” problems, often including substance abuse, depression, and
various compulsive behaviors such as self-injury, compulsive sexual
behavior, or eating disordered behavior. As opposed to those of clients
with PTSD, for whom trauma disrupted a cohesive life structure and rela-
tively good adjustment, the histories of PCA survivors, whose clinical
presentation almost inevitably is one of complex PTSD rather than PTSD,
suggest that stable adjustment was never attained in the first place.
It is this conceptual distinction that indicates the need for differential
treatment strategies for these two groups. Take affect dysregulation as an
example. One is likely to see difficulties in this area in both PTSD and
complex PTSD. In the case of PTSD, affect dysregulation is attributable
primarily to the heightened arousal of exposure to traumatic events.
Similarly, in the PCA survivor with complex PTSD, problems with affect
regulation are very likely to be compounded by the chronic arousal
created by repeated trauma. PCA survivors, however, are highly likely to
have never developed the capacities and skills required for the containment
and moderation of affective responses even prior to having encountered
explicitly traumatic events.
Performance versus Skills Deficits
In PTSD, therefore, affect dysregulation is reflective of a performance
deficit; the client has developed the capacities required for affect regulation
and manifested the capacity to exercise these abilities before they were
compromised by elevated levels of arousal engendered by exposure to
trauma. For these clients, application of any of a variety of techniques
involving exposure to traumatic material—such as prolonged exposure
(Foa & Rothbaum, 1998), eye movement desensitization and reprocessing
(Shapiro, 2001), or traumatic incident reduction (French & Harris,
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280 JOURNAL OF TRAUMA & DISSOCIATION
1999)—will be effective precisely because these clients possess the
capacity to regulate affective experience, even though this resource has
been compromised by elevated arousal. Due to their affect regulation and
affect tolerance skills, these clients can withstand the extreme stress
incited by trauma exposure techniques long enough for arousal to extinguish.
A very different set of circumstances makes these exposure techniques
at best extremely risk laden for PCA survivors with complex PTSD. For
these clients, contextual theory suggests, affect dysregulation is not a
performance deficit but a skills deficit. Due to the lack of adequate devel-
opmental resources in their early family of origin environment, these
clients never established the capacity for affect regulation. For them,
therefore, the intense affect stimulated by trauma exposure methods will
almost certainly promote decompensation rather than stabilization—
unless extensive intervention aimed at fostering the acquisition of affect
regulation skills that were never previously established is thoroughly
carried out first. This is likely the reason for the substantial dropout rate
reported in outcome studies assessing exposure therapy for PTSD, especially
among child abuse survivors (Cloitre, Koenen, Cohen, & Han, 2002;
McDonagh et al., 2005; Schnurr et al., 2007).
Affect regulation, of course, is simply one example of a literally unlimited
range of broad developmental attainments (e.g., secure attachment, self-
soothing), general capacities (e.g., establishing and maintaining friendships,
logical reasoning and decision making), and concrete skills (e.g., knowing
how to go about renting an apartment or opening a checking account) that
may need remediation in any given client with a PCA history. These are
likely to primarily represent skills deficits due to developmental gaps
resulting from having been reared in an ineffective family environment,
rather than performance deficits due to the interference of trauma-related
symptoms. Therefore, identification and remediation of these gaps in func-
tioning is an essential, central component of treatment for PCA survivors.
Awareness of and responsiveness to the ways in which these difficulties
have been compounded by trauma is, obviously, important. However, an
exclusive focus on trauma as the cause of the difficulties of these clients is
misleading and is likely to lead to serious treatment errors. To the degree
that the problems of clients in this spectrum are attributable to skills deficits,
no amount of processing of traumatic material will instill capacities that
were never learned. More important, exposure to traumatic material without
recognizing and addressing these gaps in development and practical skills
acquisition poses a serious risk of overtaxing and compromising rather
than enhancing client functioning. A cornerstone of contextual treatment
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Steven N. Gold 281
of PCA survivors, therefore, is that appreciable progress in addressing
developmental and life skills deficits must occur before direct processing
of traumatic material can be productively undertaken.
Developmental Deficits as Cause and Effect
A similar distinction could be derived from the proposed diagnostic
category of DTD (van der Kolk, 2005), which is essentially a refinement
of the concept of complex PTSD (van der Kolk & Courtois, 2005). As
evinced in the quote cited earlier, van der Kolk frames the developmental
difficulties in DTD as stemming from child abuse and maltreatment itself.
The DTD conceptualization does not in and of itself preclude recognizing
that different interventions would be needed to remediate developmental
deficits from those employed to reverse the adverse impact of abuse
trauma on adjustment. Nor does it necessarily contradict the principle that
intensive work on developmental difficulties must precede extended
focus on trauma per se. However, when the conceptual assumption is that
trauma is responsible for developmental difficulties as well as PTSD and
other symptoms, it is easy to miss this distinction and proceed as if trauma
processing will effectively address both types of problems. The danger is
that approaching treatment in this manner will at best fail to effectively
address developmental deficits, and at worst lead to deterioration in func-
tioning. The latter commonly occurring adverse outcome among many
PCA survivors is due to the absence of the coping skills needed to tolerate
and benefit from directly confronting the extreme levels of distress that
can be aroused by trauma processing.
CASE EXAMPLE: DELORES
The conceptual shift from seeing the problems of PCA survivors as
being exclusively attributable to abuse trauma to recognizing the discrete
contributions of family of origin background and resulting developmental
gaps can be a difficult one to fully grasp in the abstract. The application of
this formulation to a particular case can help bring this distinction into
focus. An instance that illustrates both the limitations of a narrowly
(and in this case ill-conceived) trauma conceptualization and the benefits
of integrating familial, social, and developmental contexts into case
formulation is the contextual treatment of Delores (name changed to
protect confidentiality).
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Background
Delores entered contextual therapy at the age of 38, soon after having
been discharged from a residential program specializing in the treatment
of trauma survivors. Married and a stay-at-home mother of two preado-
lescent children, she had long struggled with addiction to pain medication
and bulimarexia. Her most recent course of residential treatment occurred
in response to a severe relapse into active abuse of pain killers and a
resurgence of purging by vomiting and food restriction. She reported a
history of unusually severe physical and sexual abuse by her father. Her
trauma background was unusual in that both forms of abuse frequently
occurred in the presence of other family members. She, her three sisters,
and her younger brother were all beaten and sexually molested by their
father, very often in front of one another. Delores could not remember a
time when her abuse and that of her siblings was not a common occur-
rence, and she indicated that it continued until she moved out of the house
at age 16. Probably due to the presence of witnesses in many instances
of maltreatment and the degree to which it was woven into the routine
and daily life of the family, her recollections of abuse were unusually
extensive, fine tuned, and vivid.
Despite the exceptionally detailed quality of her memories of her
abuse, she told her outpatient contextual therapist that in the residential
program she was repeatedly warned that “there must be much more that
you don’t remember” because “if you remembered it all you wouldn’t
have the problems you do.” Delores claimed that she was admonished
that if she didn’t work diligently to access these additional abuse memo-
ries they would sooner or later all tumble out at once. She was further
warned that her underlying personality configuration was deeply divided,
and that when more recollections of abuse did suddenly emerge, she
would fragment and very likely become psychotic. Although she initially
did not subscribe to these beliefs and resisted them, during the course of
treatment she gradually became convinced that they were valid. As a
result, she left the residential trauma program riddled with anxiety and
terrified that at any moment even more horrendous recollections of abuse
than those that already plagued her would come flooding back.
Within a few weeks after discharge her substance abuse and bulimarexia
intensified markedly in response to her elevated and unremitting terror.
She therefore had to be admitted to residential treatment for chemical
dependency. It was the latter program that referred Delores upon discharge
to outpatient contextual treatment. When outpatient therapy began she
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Steven N. Gold 283
met full criteria for PTSD and suffered from episodes of dissociative
amnesia several times a week that lasted hours or in some instances days,
severe insomnia, intense headaches, and extreme social avoidance.
Shifting Focus from Past to Present
Due to Delores’s continued chronically anxiety-ridden state, the first
few months of contextual treatment centered on the following goals:
(a) Developing a therapeutic alliance characterized by a supportive and
encouraging tone rather than what she perceived to have been a punitive
and admonishing stance on the trauma unit; (b) reducing her preoccupation
with uncovering abuse by actively and repeatedly reassuring her that
trauma that is remembered can be just as disturbing and disruptive to
functioning as unrecalled trauma and by challenging the beliefs she had
acquired in residential treatment that at any moment additional abuse
recollections would suddenly emerge and overwhelm her; and (c) providing
her with a range of strategies for reducing her level of arousal, diminishing
her intrusive preoccupation with her abuse history, and increasing her
capacity to stay grounded in the present.
Despite intermittent progress in these areas, Delores continued to
struggle with her fear that she would be overwhelmed with new abuse
recollections and decompensate. Approximately 3 months into outpatient
treatment she therefore again relapsed into substance abuse and became
actively suicidal. This led to her being involuntarily hospitalized for several
days and discharged back to outpatient therapy. In her first session after
discharge from involuntary hospitalization she told her therapist that the
experience of becoming so overwrought that she resumed drug abuse and
became suicidal powerfully demonstrated to her how counterproductive it
was to continue focusing on the past. She consequently committed herself
to “facing my fears and living life today.”
Remediation of Developmental Gaps
Within a month after resuming outpatient treatment with this new
perspective and intensified investment, Delores reported a noticeable drop
in her level of anxiety, dissociative fogginess, and tenuous awareness of
her surroundings. Over the next 6 months she successfully maintained
abstinence from substance abuse and became progressively less anxious,
less dissociative, and more outgoing. As she became less haunted by
the past and more aware of the present her recognition of the impact of
contemporary factors on her outlook and functioning sharpened considerably.
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284 JOURNAL OF TRAUMA & DISSOCIATION
She gradually noticed accumulating evidence that in various ways her
husband maintained a controlling stance in their relationship. She saw
that previously each time she had encountered signs that he was untrust-
worthy, unfaithful, or manipulative, she had floated off into periods of
dissociative spaciness that had lasted for hours or days at a time. By the
time each of these periods ended she had forgotten the material that had
set it off, which prevented her from becoming fully cognizant of the
ongoing power inequity in the relationship. Increasingly she was able to
face these indicators as they occurred, with a simultaneous decrease in
dissociative episodes and a much keener awareness of the power dynamics
in the relationship.
A related issue that emerged and became an ongoing theme in treatment
was confusion about interpersonal relationships and trust. Although
her father had clearly betrayed her intensely and repeatedly, he had also
frequently warned her that people outside the family could not be trusted.
When she later encountered several instances of betrayal by people
outside the family, this seemed to confirm her father’s contention. Over
the years she frequently would enter into friendships only to find herself
taken advantage of and mistreated. As a consequence, she alternated
between phobic avoidance of social interactions and letting her guard
down only to find that she had once again misplaced her trust. She grew
progressively unsure of herself and wary of others.
What she failed to realize was that a major maintaining factor in this
pattern was a developmental gap: Delores had never learned how to accu-
rately gauge others’ trustworthiness. Over time she was taught in therapy
to wait and observe others closely before deciding whether they were
reliable enough to engage with. She was taught to pay close attention to
what others said, to assess whether their statements were consistent over
time, and above all to evaluate whether their behavior was consistent with
their verbalizations. Slowly she became less fearful of venturing outside
the house and entering into social situations. She began to have more and
more frequent casual interactions with others in the neighborhood and
soon started establishing ongoing social connections.
She also came to realize that her general upbringing, in combination
with her abuse, interfered with her ever having learned how to recognize
her feelings and wants and communicate them effectively to others. Over
time she came to see how these factors fueled the power imbalance in her
relationship with her husband, her peers, and even her children. As she
continued to develop social relationships and supports she also learned
how to identify what she wanted and how to productively convey her
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Steven N. Gold 285
wishes to others. As a result her relationships became increasingly
balanced and equitable. She also became aware that her anxiety and limited
development had fueled a perception of herself as a helpless child that
assumed a dependent and relatively powerless stance with her husband
and others. As she learned new interpersonal and adaptive coping skills
such as assertiveness and self-soothing she began to establish a solid
sense of self-confidence and self-esteem.
Distinguishing Past from Present
About 6 months following her involuntary hospitalization due to her
drug abuse relapse and suicidality, her anxiety, dissociative episodes,
reclusiveness, and self-doubt resurfaced. Ironically, throughout this 6-month
span of treatment, although no longer feeling pressured to remember and
address her memories of abuse, she began to be able to spontaneously
connect her current difficulties to their antecedents in her traumatic child-
hood and disturbed family dynamics. As a result, she was able to identify
that her increased distress and deteriorating functioning were related to
the calendar. The period from Halloween through New Years had been
the worst time of year when she was growing up, because the chaos and
conflict in the family intensified greatly during the holiday season.
In the wake of her struggles with the dysphoria this time of year
brought on, she resumed abusing drugs. This time, however, she almost
immediately took it upon herself to voluntarily enter residential chemical
dependency treatment at the same facility where she had been previously.
Upon discharge and resumption of outpatient treatment she quickly
resumed her regimen of self-care, anxiety reduction exercises, and
grounding techniques. Simultaneously, therapy focused on helping her
to master several important capacities she had never learned as a child:
identifying her own feelings, wishes, and wants; assertively communicating
her feelings and preferences; setting reasonable boundaries so that she
was not overly focused on tending to others’ needs to the relative exclusion
of her own; and balancing her family responsibilities with addressing her
own needs.
As a result, the holiday season was much more pleasant than usual,
with less intrusive recollections about how painful that time of year had
been throughout her childhood. She discovered that the more upbeat and
actively involved in her life she was, the less power her husband seemed
to have to manipulate her and disrupt her sense of well-being. A noteworthy
incident occurred a few days after Christmas. She experienced a particularly
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286 JOURNAL OF TRAUMA & DISSOCIATION
intense flashback in which she suddenly felt the way she did as a child
when her father was about to physically assault her. However, she found
that rather than being pulled further and further into this experience, she
was able to successfully employ anxiety reduction and grounding strategies
to quickly end the flashback. In the early months of the new year, her
expanding capacity to interact more productively with her husband and
children and to consistently maintain self-care routines fostered increasingly
stable feelings of being safe, secure, at ease, and happy. As her ability to
disrupt flashbacks and distract herself from traumatic recollections became
more and more ingrained and freed her from a constant sense of resignation
and dread, she reported, “I feel that I have my life back.”
Claiming a Life in the Present
For the first time since she had been married Delores began to
seriously consider working outside the home, a goal that was associated
with a sense of satisfaction as well as of the potential for independence
and freedom from being trapped in financial reliance on her husband. As
she pondered what type of work to pursue, she commented in session,
“The world holds so many possibilities for me. . . . That’s why I think it’s
important to have a job—at least put my foot out into the world instead of
stay at home and waste away.” She initially considered taking a brief
course as a medical lab technician and entering this field but decided
instead to set her sights higher and enter an 18-month course of study to
become a surgical technician. There was considerable anxiety about
whether she had the academic ability to be successful. As she steeled
herself to begin school, she continued working on resisting the pull to
ruminate about her abusive childhood while developing the emotional
regulation and assertiveness skills to interact more productively with her
husband and children in the present.
When she did enter technical school, she was amazed to find that she
was able to master the course material and maintain excellent grades.
With the boost in confidence this experience provided, she decided to
“upgrade” her career ambitions and pursue a degree as a registered nurse.
At this point, having stabilized the gains she had made in therapy and
with increasing demands school was making on her time, she decided she
was ready to terminate 21 months after entering outpatient treatment.
In a phone call approximately a year and a half later, Delores reported
that she continued doing well in school. She commented that the diffi-
culty and pressure of the registered nurse program had led several of her
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Steven N. Gold 287
friends to drop out: “Last semester people were breaking down in tears.”
In contrast, not only had she persisted in her studies, but thus far she had
only received a B grade in one course; all of her other grades were As.
Having a stable group of friends was a new experience for Delores. She
indicated that she had put into practice what she had learned in therapy
about how to determine who was worthy of her trust and could be counted
on to maintain a healthy balance of give and take in a relationship. She
credited many of the positive changes in her life to having established a
daily routine of self-care that she had never learned growing up:
Once you start doing these things you can recognize the world is
safe. . . . There’s still unsafe people out there, but like I learned in
therapy, you don’t just jump into friendships. You watch people
over time and see who you can trust and who you admire.
Delores also described a radical shift in perspective about her family
since she had begun contextual therapy, much of which she credited to
“just your [her therapist’s] reassurance that it’s OK to let go of the past”
instead of having to struggle to remember more than the extensive recol-
lections she already possessed: “The loyalty [to her family of origin] was
so strong it was hard to just let go.” She explained that she had been
consumed with the belief that somehow her childhood maltreatment had
been her own fault. “Maybe,” she had repeatedly told herself, “I made my
father angry.” However
. . . the more I think about it, my parents did not like me. My father
cared about me more than my mother did. She was not nurturing at
all toward me, whereas with my sisters she was more involved in
their lives. I look at my own kids and say to myself, “How could
even a 13-year-old be responsible for what happened?” And now
I’m just sad for my mother for missing out.
She concluded, “It’s just the way it was. I’m never going to solve this
mystery puzzle. There’s nothing to solve. That’s just the way it was.”
As for her current life, she stated:
. . . therapy changed my whole life because it gave me the power to
make choices. Like nobody ever said to me, “You have the power to
let go. You don’t have to remember everything.” [The abuse memories]
are only in my mind if I let them in my mind. Sometimes things
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come up, but it’s not like I’m overly distraught about it. It comes
into my mind and I notice it and then let it go.
Life is good, it really is. My husband is very negative. He complains
all the time. If he didn’t have anything to complain about he’d have
nothing to do. So I try to stay away from that. I try to stay on the
positive side. I just got tired of torturing myself. It was time to let go.
I spent too many years paying tribute to it. I always felt so helpless.
It’s a hard balance between schoolwork, and the kids and the house.
But I’m doing really good personally. I feel much more safe and
assertive in the world.
IMPLICATIONS AND CONCLUSIONS
The development of trauma-focused treatment over the past few
decades has provided those clinicians who have been exposed to it with a
powerful context for understanding and addressing otherwise mystifying
and insoluble problems. Contextual therapy for PCA survivors aims to
augment the effectiveness of a trauma-focused approach by fostering
awareness of the contribution of other contexts besides trauma to the
difficulties of this population. Clinical experience and research evidence
both suggest that in addition to the explicit abuse trauma to which they have
been subjected, PCA survivors also often are reared in family environments
that both foster their risk of maltreatment and hinder their psychological
development. As a result, PCA survivors often reach adulthood not only
with trauma-related symptomatology, but without the developmental
capacities and practical skills needed for effective functioning.
A crucial difference in focus between a trauma-focused approach to
treating PCA survivors and a contextual approach is the way in which
outcome is likely to be conceptualized. When trauma is seen as the central
cause of client problems, those difficulties are likely to be perceived
primarily in terms of the trauma-related symptomatology encompassed by
diagnostic categories such as PTSD or complex PTSD. The practitioner
who thinks in terms of these disorders will be inclined to see the goal
of treatment as being the reduction or elimination of symptoms. From a
contextual perspective, trauma-related symptoms are only one sector of the
PCA survivor’s problems, and it may not even be the most important sector.
Implicit in the Diagnostic and Statistical Manual of Mental Disorders
classification system is the principle that behavioral deviations alone are not a
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Steven N. Gold 289
sufficient basis for making a psychiatric diagnosis. The diagnostic criteria
make it explicit that the yardstick for determining whether a mental disorder
exists is that in addition to the presence of symptoms, there must be evidence
that the behavior in question results in “significant impairment in social, aca-
demic or occupational functioning” (see, e.g., American Psychiatric Associa-
tion, 2000, p. 468). Contextual theory suggests that the appreciable social,
academic, and occupational limitations often seen in PCA survivors are not
merely a consequence of survivors’ psychological symptoms but are also and
primarily a reflection of a truncated developmental trajectory resulting largely
from having grown up in an ineffective family environment. From a contex-
tual conceptual perspective, most PCA survivors enter adulthood without the
requisite capacities to function at a developmentally appropriate level and to
establish a stable life structure. Therefore, rather than assuming that either
trauma or symptom resolution will reverse this functional impairment, a
major thrust of contextual therapy is to directly target the impairment through
remediation of developmental achievements that were never attained.
As the case of Delores illustrates, excessive focus on abuse trauma
itself is often counterproductive for survivors of complex trauma, who
never established basic adaptive coping skills that are an inherent part
of the repertoire for people who were reared in more effective family
environments. Assisting these clients to not only become firmly grounded
in the present, but also acquire the skills they need to lead fuller lives in
adulthood, is often a much greater priority than is the processing of
trauma material. As her course of therapy also demonstrates, however,
processing of traumatic material, albeit in a way that is strongly focused
on distinguishing past from present, remains a central aspect of treatment
in contextual therapy. By helping PCA survivors to free themselves from
being perpetually haunted by the past while furnishing them with tools for
living more effectively in the present, contextual therapy aims to foster
embarkation on a trajectory that leads to continued growth and further
gains in adaptive functioning long after termination of treatment. This
certainly seemed to have been the case for Delores.
The impetus for the creation of contextual theory and therapy was to
find an intervention approach that would meet the unique needs of PCA
survivors, who compose an appreciable proportion of the general clinical
population. Despite the evolution of trauma-related research and clinical
practice since the closing decades of the 20th century, psychological
trauma has yet to be seen as a central topic in the mental health professions.
It has not yet been adopted in the core curricula of the training of mental
health professionals (Courtois, 2002) and therefore escapes the attention
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290 JOURNAL OF TRAUMA & DISSOCIATION
of most practitioners. By integrating the context of trauma with those of
family environment and development, contextual therapy has the potential
to help bring the treatment of psychological trauma more squarely into the
mainstream of mental health practice.
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RECEIVED: 04/16/07
REVISED: 07/27/07
ACCEPTED: 09/14/07
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