Journal of Emotional Abuse

ISSN: 1092-6798 (Print) 1540-4714 (Online) Journal homepage: https://www.tandfonline.com/loi/wjea20

Trauma and the Self

A Theoretical and Clinical Perspective

Laurie Anne Pearlman PhD

To cite this article: Laurie Anne Pearlman PhD (1997) Trauma and the Self, Journal of Emotional
Abuse, 1:1, 7-25, DOI: 10.1300/J135v01n01_02

To link to this article: https://doi.org/10.1300/J135v01n01_02

Published online: 22 Oct 2008.

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 Trauma and the Self:
A Theoretical and Clinical Perspective
Laurie Anne Pearlman

AB!XRACT. Constructivist self development theory (CSDT) provides a

theoretical framework for understanding the impact of trauma on the
self. The theory integrates psychoanalytic theory with theories of
social cognition. This article describes the impact of childhood abuse
and neglect in a CSDT framework, focusing on the self capacities, or
inner abilities that maintain a cohesive, consistent sense of self. The
article outlines the psychological and behavioral sequelae of undevel-
oped self capacities resulting from emotional trauma. It then provides
a detailed approach to the psychotherapeutic development of self
capacities. [Artick copies available for a fee fiom Tite H m r t h Document
Delivery Senke: 1-800-342-9478. E-mail addm: getinfoo@hnworth.com]

KEYWORDS. Child abuse, identity, child development, emotional

abuse, self capacity, psychological maltreatment, trauma

Survivors of childhood abuse and neglect, their loved ones and thera-
pists are aware of the difficulty many survivors have engaging in trusting,

Laurie Anne Pearlman, PhD, is a clinical psychologist and Research Director

at the Traumatic Stress tnstitutdCenter for Adult & Adolescent Psychotherapy
LLC. She is also President of Trauma Research, Education, and Training Institute,
Inc. Her work includes theory-building, writing, research, psychotherapy and
supervision, all related to traumatic stress.
Address correspondence to: Dr. Laurie Anne Pearlman, TSIKAAP, 22 Mor-
gan Farms Drive, South Windsor, CT 06074, USA.
The author wishes to thank Pamela J. Dieter, PhD, Richard Nicastro, PhD,
Anne C. Pratt, PhD, and Karen W. Saakvitne, PhD for comments on an early draft
of this manuscript.
This article draws upon previous works (McCann & Pearlman, 1990; Pearl-
man & Saakvitne, 1995a).
Journal of Emotional Abuse, Vol. 1( 1) 1998
0 1998 by The Haworth Press, Inc. All rights reserved. 7
8 JOURNAL OF EMOTIONAL ABUSE

consistent relationships with others. As painful as these troubled relation-

ships are for survivors, perhaps the more intimate trauma for many is the
daily confrontation with oneselfi the lack of connection with oneself, a
precarious or tentative sense of self-cohesion, and a perpetual sense of
imminent shame, terror, and dissociation. I
Childhood maltreatment (sexual, physical, and emotional) has a pro-
found and pervasive impact on all aspects of the self. A psychological
theory can provide a framework for victims, survivors and therapists to
understand the complex and agonizing aftereffects of trauma; such a
framework then provides guidelines for healing. This article describes the
impact of trauma on the self within the framework of constructivist self
development theory (CSDT; McCann & Pearlman, 1990; Pearlman &
Saakvitne, 1995a, 1995b). The goal of this article is to review and expand
upon CSDT’s descriptions of the effects of early emotional abuse on the
self in order to provide guidelines for clinicians as well as more detailed
groundwork for future research on trauma and the self.

CONSTRUCTIVIST SELF DEVELOPMENT THEORY

CSDT integrates psychoanalytic theories, particularly object relations

theory (Mahler, Pine, & Bergman, 1975; White & Weiner, 1986), interper-
sonal psychiatry (Fromm-Reichmann, 1960; Sullivan, 1953), and self
psychology (Kohut, 1977), with theories of constructivism (Mahoney,
1981; Mahoney & Lyddon, 1988), social learning (Rotter, 1954, 1982),
and cognitive development (Piaget, 1971). CSDT views the unique impact
of trauma as arising from an interaction of the aspects of the event that are
psychologically meaningful to the individual with aspects of the individ-
ual, including his or her psychological resources, defenses, and needs. The
impact of trauma is further shaped by the cultural and social context within
which it occurs.
CSDT delineates aspects of the self that are impacted by trauma. These
include frame of reference (one’s overarching ways of viewing self and
world), psychological needs, ego resources, the memory system, and self
capacities. The theory has been described in greater detail elsewhere
(McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995a, 1995b). The
present article focuses on the self capacities, the foundation of the individ-
ual’s relationship with himself or herself and his or her psychological
ability to exist in the world. The article includes a discussion of the psy-
chological and behavioral sequelae of undeveloped self capacities and
pychotherapeutic interventions to develop self capacities.
 Laurie Anne Pearlman 9

Self Capacities
Self capacities are inner abilities that allow an individual to maintain a
consistent, cohesive sense of self. These abilities or self capacities develop
through early relationships with caregivers and regulate one’s inner states,
contributing to inner balance. CSDT describes three self capacities: the
ability to maintain an inner sense of connection with others; the ability to
experience, tolerate, and integrate strong affect; and the ability to maintain
a sense of self as viable, benign, and positive. The first self capacity
(connection) makes the other two (affect regulation and self-worth) pos-
sible through the internalization of loving others in the context of a secure
attachment relationship (Bowlby, 1988) or holding environment (Winni-
cott, 1965). Self psychologists have eloquently described the early devel-
opment of the self (Kohut, 1977; Mahler et al., 1975; White & Weiner,
1986). As these theorists describe, the emergence, differentiation, and
development of the self is facilitated by sensitive caregivers who respond
to the child’s needs, mirror inner states and behaviors, and protect and
encourage the child’s individuation which provides an emotionally secure
base from which the child grows (Bowlby, 1988). The self capacities
cannot develop properly in an abusive or neglectful home. Researchers
using Bowlby’s work as a foundation have found a range of attachment
relationships from secure to disorganized; Bowlby’s attachment theory
and Ainsworth’s security theory are integral to the conceptualization pre-
sented here (see Bretherton, 1992, for a comprehensive review of these
theories).

THE DEVELOPMENTAL IMPACT OF MALTREATMENT

ON SELF CAPACITIES

Connection
The healthy development from childhood into adulthood of the capacity
to maintain an inner sense of connection with benign others runs along a
continuum from the use of others to gratify needs, to the use of others as
judges of one’s self-worth, to the internalization of others who are experi-
enced as separate and as stable sources of internal support. Repeated abuse
and chronic neglect by parents, siblings, or other presumed caretakers
interfere with the internalization of loving others; the caretakers who
should be attending to the child’s safety and well-being are not, and so
they cannot be taken into the child’s inner world as a protective presence
(Bowlby, 1988; Davies & Frawley, 1994). Children learn a powerful les-
10 JOURNAL OF EMOTIONAL ABUSE

son: that they are helpless to protect themselves and that others will not
protect or assist them. The inadequate development of this self capacity
interferes with the development of the other two: affect regulation and self
worth are fundamentallybased in the internalization of loving others.

Affect Regulation
Under ideal conditions, this self capacity‘develops from undifferentiated
affect states through an ability to distinguish pleasurable from painful states,
to the ability to identify and hold various states sequentially or simulta-
neously. In adulthood, people in whom affect regulation is not well devel-
oped may somaticize, suppress or avoid affect altogether, and/or discharge
affect through action. Well-developed affect tolerance includes the ability to
tolerate ambivalence and disappointment, to accept responsibility for one’s
mistakes and failures, and to mediate affect with words and imagery.
In an emotionally abusive home, the child’s feelings are not validated.
When she cries, no one says, “of course you’re scared (or angry or tired).”
Thus the child does not learn the names for feelings. Feelings can also be
dangerous for the child living in an abusive home because feelings lead to
needs. An expression of needs can in turn lead to an awareness of parental
neglect or to humiliation, shaming, violence, or other abuse. The child
may then experience normal needs with self-loathing or fear. The child
may eventually learn not to feel, using denial, dissociation, or self-destruc-
tive behaviors (Deiter & Pearlman, in press). These defenses may come
into play at a young age for many abused children, interrupting the devel-
opment of affect regulation and the evolution of an integrated self (Men-
nen & Meadow, 1994).
The abused child does not learn to self-soothe. When she hurts, no one
comforts her, telling her, “you’ll be all right.” There can be no internaliza-
tion of soothing others when the response to the child’s fears or pain is at
best neglect and at worst abuse (e.g., “I’ll give you something to cry
about”).
For children, attention from someone important can be intensely plea-
surable in the context of a life otherwise devoid of attention and touch.
Later, when the child becomes aware of the exploitation and betrayal that
are the context for that abusive or inappropriate connection, feelings of
bewilderment and shame, disgust and self-loathing may emerge. Any and
all of these feeling states may persist into adulthood.
While many feeling states may become inaccessible or disavowed,
shame may endure. Feeling responsible for their own abuse, pain, or
neglect consolidates shame. Feeling like a conspirator, the child may begin
to identify with the perpetrator. Confusion and self-loathing are likely
 Laurie Anne Pearlman 11

outcomes of such an identification. This identification is one of the under-

pinnings of the internal fluidity among the identities of victim, perpetrator,
and bystander that survivors and their therapists experience in subsequent
psychotherapy (Davies & Frawley, 1994; McCann & Pearlman, 1990;
Miller, 1994; Pearlman & Saakvitne, 1995a; Wilson & Lindy, 1994).
When the abuse is emotional but not physical, these same feelings may
emerge, but without the physical evidence the child may feel s h e requires
to make sense of them. Emotionally abused children (and then adults) may
feel like they are crazy or “making it up,” that they are set apart from
others by their secret shame, yet unable to understand why they feel so
bad, so angry, so different.
These difficulties cam be compounded by dissociation, a natural
response for some to severe or early abuse (Putnam, 1989). When it
persists into adulthood, dissociation can become an automatic response to
the earliest stirrings of any feelings, thus standing in for (and in the way
of) affect. This process prevents the individual from learning what the
experience of feelings is like, what the natural course of each feeling state
is for that child.
Seu- Worth
The developmental continuum of this self capacity begins with the self
being experienced as alive when active; when inactive or in a negative
feeling state, the experience may be one of nonexistence. With increasing
development, the self is experienced as existing or worthy when the indi-
vidual receives recognition from others. In later development, the individ-
uals assume their own psychological self-regulating functions and can
differentiate between a bad or wrong act and their fundamental self-worth.
Perpetrators may reinforce the child’s isolation by conveying that the
adult’s abusive behavior is in some way reserved for this child because of
the child’s special status, that the child’s continuing compliance with the
abuser’s needs and demands are making the adult’s life better or worth-
while, or that the child’s compliance is protecting other family members
from harm. The natural desire every child has to feel special becomes
tainted, again leading to confusion, self-abnegation, shame, and self-loath-
ing. Identification with the abuser’s projections onto the victim or internal-
ization of the self as described by the abuser’s words and behaviors also
result in confusion and profound self-loathing.

PSYCHOLOGICAL AND BEHAVIORAL SEQUELAE

Undeveloped self capacities imply difficulties being alone without feel-
ing lonely or anxious, avoidance of feelings or situations (such as relation-
12 JOURNAL OF EMOTIONAL ABUSE

ships) that might evoke feelings, craving nurturance (although this may
not be within the survivor’s awareness, or may be experienced as loath-
some, disgusting, and dangerous), questioning one’s right to exist, experi-
encing oneself as toxic, and having difficulty meeting one’s own needs.
Dissociation, substance abuse, and self-destructive behaviors may be
attempts to compensate for missing self capacities. While self-destructive
behaviors may represent traumatic reenactments and a form of behavioral
memory, they arise from undeveloped self capacities (Deiter & Pearlman,
in press). As self-loathing, shame, self-fragmentation, or other threatening
states emerge, the survivor may automatically dissociate, or may take
action (such as consuming alcohol or other drugs or injuring her body) to
eradicate these frightening possibilities. Feelings that some people find
pleasurable, such as love, intimacy, or sexual arousal are often confusing
and threatening for survivors, as connection historically may have meant
subjugation, symbiosis, vulnerability to abandonment, or abuse. The vic-
tim or survivor may need to flee these feelings as well in order to maintain
a cohesive sense of self
Thoughts of suicide, which are distinct from self-harming behaviors,
can also serve as a stand-in for self capacities. The awareness that the
survivor could end his or her suffering at any time sometimes is the only
thing that makes living bearable. There is at least this one ultimate thing
one can control.
Connection
The lack of an internalized protective presence is a major factor in
many survivors’ relationship with themselves, including their self-harm-
ing behaviors (Miller, 1994). There may not be internalized benign others
to draw upon in times of crisis, no inner resources to help overcome
loneliness or self-doubt. The profound aloneness the survivor may experi-
ence can be the basis for shame, self-loathing, or despair. The lack of
internalized positive others interferes with the development of healthy
relationships, including the therapeutic relationship. Clients in whom this
self capacity is undeveloped will have great difficulty imagining that the
therapist (or anyone else) cares about them or that the therapist’s caring
could be without a hidden agenda to harm them.
Behavioral sequelae of the underdevelopment of the capacity for inner
connection include difficulty managing boundaries in relationships. These
individuals may feel strong, immediate attachments to people who demon-
strate any kindness toward them, or they may feel a relationship is pro-
foundly damaged when the other party fumbles interpersonally. Intimacy
dlficulties, including avoiding relationships and connecting without ade-
 Laurie Anne Pearlman 13

quate self-awareness, are a common problem for emotional abuse survi-

vors without strong inner connections to caring others.

Aflect Regulation
Childhood experiences of physical, sexual, or emotional maltreatment
suffise children’s relationships with themselves with negative affect. Mal-
treated children may negate themselves, demonstrated most clearly in
some individuals with dissociative identity disorder (American Psychiatric
Association, 1994), within whom one state denies the existence of others.
These survivors may loathe, detest, or rage against themselves. These
feelings are often manifest in destructive behaviors directed against one’s
own body (such as cutting, burning, punching, pain-inducing masturba-
tion, bulimia or anorexia) or risk-taking such as drunken driving or engag-
ing in high-risk sexual behaviors (unprotected intercourse or sexual activ-
ity with strangers). In milder forms, self-loathing may be acted out
through unremitting self-recriminations, shame, or guilt or denying one-
self pleasure or interpersonal connection. Self-negation may also take the
forms of emptiness, numbness, and disconnection. In these states, self-de-
structive behaviors may serve to reify affect, to validate one’s existence or
humanness, to counteract dissociation by creating sensation, to restore a
sense of being alive (van der Kolk, 1996) and to make one’s body and pain
visible (Briere, 1992; Calof, 1995a,b; Miller, 1994).
The pervasive shame that can accompany abuse or neglect may be
intolerable. Survivors may feel shame about feelings, thoughts, and
actions, about their bodies and natural bodily functions, and about sexual-
ity (Saakvitne, 1992). They may feel shame about their needs, and about
existing. Beere (1989) has applied Kaufinan’s (1985) model of shame to
the understanding of trauma. Within this model, shame is conceptualized
as arising from a sense of disconnection from the other coupled with a
sense of inferiority, a framework supported empirically by Wong and
Cook (1992). Acts of self-mutilation can resolve the moment of shame by
shocking individuals back into connection with their bodies and the pres-
ent moment, by meeting the survivors’ needs for punishment, or by creat-
ing a concrete manifestation of their psychological experience of self-deg-
radation.
The irritation, annoyance, or anger that for others signal something
going wrong do not serve that purpose for people whose self capacities are
undeveloped. When feelings cannot be experienced or named, they cannot
serve their important function of providing information about psychologi-
cal needs and interpersonal relationships. They cannot help the person
move toward safety and away from danger. Instead, the survivor may
14 JOURNAL OF EMOTIONAL ABUSE

respond like a deer, caught in the headlights, paralyzed and destined for
retraumatization.
Self capacities allow people to experience ambivalence, to hold contra-
dictory thoughts or feelings simultaneously. Without this ability, the world
must be made black or white, right or wrong. Relationships thus become
potential minefields: “If you don’t agree with me, you must hate me.”
The frustration that arises in everyday life may be vented outward
rather than held, examined, and processed. Anger may be expressed
through violence. Abused children may harm younger children or pets
through abuse, or their peers through bullying. Schoolchildren may direct
their unformed rage at teachers or at other adults who do not set limits or
help children find words for their feelings. Accepting responsibility for
one’s mistakes requires well-developed self capacities; blaming others
may substitute for managing painful feelings and sitting with disappoint-
ment, guilt, regret, or remorse.
Alternatively, frustration or other emotional distress may be directed
against oneself through self-destructive behaviors. Or the individual may
withdraw into a vacuous inner world, one that offers relief at the moment
but renders a screaming void over time. For some survivors, thoughts of
suicide are a first, rather than a last, resort. Even the mildest negative inner
state may be experienced as traumatic (van der Kolk, 1994) and may
precipitate thoughts like “I have to kill myself” or “I do not belong in the
world.” A common behavioral manifestation of the lack of affect toler-
ance is the attempt to exert control over oneself and in relationships with
others. In treatment, this client may need to control his or her own expres-
sions of feelings and may express dismay or suspicion when the therapists
show their feelings.
Self- Worth

Children from neglectful or abusive homes eventually conclude that

they are different from others. For most of these children, “different
from” means “less than.” The adult survivor’s question, “what is nor-
mal?” bespeaks a lifelong preoccupation. Healthy socialization does not
occur, so the child is endlessly attempting to try to figure out what to do
and how to do it in social situations, furtively trying to pass as a n o d
person, and eternally feeling inadequate and frustrated in these efforts.
Social withdrawal or the use of a false self in interpersonal situations are
solutions to this problem. These solutions result in enormous, sometimes
existential, loneliness. When individuals are cut off from their inner life as
well, because of its terrors, they become enshrouded in despair.
Survivors of childhood abuse or neglect may feel profoundly different
 Laurie Anne Pearlman 15

or alienated from others. They may struggle to accept or feel good about
themselves, or even to feel entitled to exist. These feelings may shape an
individual into a driven achiever who is never gratified or a person who
cannot bear to try anything new because of fear of failure. In research on
cognitive schemas, Black and Pearlman (in press) found that beliefs about
self-esteem mediated the relationship between beliefs about self (in the
areas of trust and intimacy) and beliefs about others (also related to trust
and intimacy). This finding implies that feelings of self-worth are central
to one’s relationship with one’s inner world and with other people.

PSYCHOTHERAPEUTIC INTER VENTIONS

Intervention Strutegy

The purpose of psychotherapeutic work on self capacities, or “self

work,” is to help the victims or survivors know, accept, and eventually
value themselves and their innermost experience, to experience a full
range of feelings, and to create a new, complex, integrated identity. Self
capacities are essential to the client’s safety. This is nowhere more obvious
in therapy than in instances of the premature exploration of traumatic
memories; without the ability to manage strong affect, trauma memories
will evoke intolerable states. A shift into a crisis state signals the need to
return to work on self capacities. Self work begins the moment the child-
hood abuse survivor client enters treatment and continues throughout the
course of the therapy.
The development of self capacities is clearly long-term work; the psy-
chological sequelae of a neglectful or abusive childhood home, which may
include a lifetime of avoiding feelings and psychological instability, can-
not be turned around in a matter of a few months. The therapeutic relation-
ship, which is the vehicle for the development of the self capacities, will
take time to build. Survivors of childhood abuse and neglect have learned
many survival lessons, and one of them is not to trust others who are
supposed to be nurturant.
Individuals without well-developed self capacities may have very
strong ego resources, resources that will be helpful to the therapy process
and that help protect the survivor from future harm. CSDT defines ego
resources as inner abilities to meet psychological needs, abilities used to
manage the interpersonal world. They include the abilities to make self-
protective judgments, to establish boundaries, to know one’s needs, to
introspect, to foresee consequences, to establish mature relations with
others, empathy, sense of humor, intelligence, will-power, and initiative.
16 JOURNAL OF EMOTIONAL ABUSE

Many survivors maintain high-level jobs, parent effectively, and evidence

strong ego resources; yet their inner lives may be filled with terror, rage, or
grief, or may be, simply and painfully, empty.

The Therapeutic Relationshe

Self capacities are developed through the creation and elaboration of a
therapeutic relationship. A healing relationship between client and thera-
pist is one that is boundaried and respectful of both parties. It is built on
authenticity: not the self-disclosure of the therapist’s personal life, but the
thoughtful use of the genuine feelings and thoughts of the therapist as a
participant in the healing process. Through the development of such a
relationship, clients over time are seen, acknowledged, and known. They
internalize the therapist’s caring, concern, and respect. They begin to
recognize that connection with the therapist is possible, and even helpful,
and use it to sustain them even when the therapist is not physically present.
The stage is then set for a different kind of relationship with oneself, which
in turn can lead to a different kind of relationship with others (Black &
Pearlman, in press).
How does it work? Therapist and client start by negotiating a frame for
the therapy. By inviting the client to speak needs and preferences (perhaps
about frequency of meetings, form of address, etc.) and feelings about the
therapist’s proposed frame (perhaps about fees, length of sessions, etc.),
the therapist conveys to the client that they are partners, that the client is
not a victim of yet another authoritarian relationship. The therapist invites
the client at the earliest moments of the treatment to begin to notice
feelings and needs, to tolerate conflict, to negotiate, and to remain aware
of ambivalence, processes from which the survivor may have withdrawn
in the forgotten past. By naming interpersonal processes, therapist and
client are breaking old rules of silence and secrecy. By inviting the client
to notice what s h e feels, the therapist helps the client begin to develop an
awareness of feelings, give them names, tolerate and voice them. Sessions
with survivors are often concluded with the question, “What will you be
needing in the hours and days ahead?” Initially, many clients find the
question inscrutable. Over time, they approach it creatively, playfully, and
gratefully.
A therapeutic relationship that is based in authenticity is one that con-
veys hope for a different kind of reality than childhood abuse and neglect
survivors may have known. It is a relationship that is more complex in that
it can include both caring and conflict. Conflicts inevitably arise related to
the frame of the therapy (the client requesting a reduced fee, longer ses-
sions, a hug), to the therapist’s errors or empathic failures (being late for
 Laurie Anne Pearlman 17

an appointment, missing the point of what the client is saying), or to client

behaviors the therapist finds difficult (self-mutilation, revictimization, or
other reenactments; Gamble, Pearlman, Lucca, & Allen, 1994). The thera-
pist commits to resolving conflicts constructively within the relationship.
This attaches new meanings to conflict: it does not have to be a matter of
right or wrong, win or lose. It may be new for the survivor to be in a
relationship where differences can exist and can be addressed and
resolved. Allowing the natural (and active) resolution of a conflict over
time gives the survivor practice in sitting with uncomfortable feelings. The
holding environment of the therapeutic relationship (Winnicott, 1965)
makes this possible. The therapist may have to reiterate “We can work this
out,” or “I’m committed to this relationship” to help the client endure and
combat fears of abandonment. Through this process, aspects of the client’s
self that were disavowed in order to maintain a sense of connection to the
primary caregivers emerge in treatment and become integrated into the
self. Over time, the client comes to embrace and eventually voice a com-
mitment to the relationship; this is a turning point, signaling the emergence
of the self capacities that make relationships possible.
Experiencing and resolving interpersonal conflicts also sets the stage
for a new relationship with inner conflict. The therapist helps the client
make sense of contradictory or mixed feelings and shifting inner states.
This allows the new possibility of understanding, accepting, and resolving
inner conflicts, leading to a stronger relationship with oneself.

Specific Interventions

Reflecting CSDT’s integration of psychoanalytic and cognitive theo-

ries, interventions are twofold: they involve exploration of history and
meanings and cognitive-behavioral interventions to help the victim or
survivor accomplish goals.

Ability to Maintain Inner Sense of Connection with Loving Others

Exploratory work. The initial approach is an assessment? Who lives in

the client’s inner world? Is the inner landscape peopled by harsh, punitive,
or abusive others? In persons with dissociated identities, these others may
be represented by distinct ego states. In more integrated individuals, these
negative introjects may be less evident yet no less present. The therapist’s
task includes exploring the client’s inner voices. Which voices and mes-
sages come in response to particular feelings? The internal response to
vulnerability may be shaming, to longing may be punishment, to entitle-
18 JOURNAL OF EMOTIONAL ABUSE

ment may be sarcasm. What is it for this individual? What are the histori-
cal roots of these responses? If the individual once had, but has subse-
quently lost, an internalized benevolent other, how did the loss come
about? This information has important implications for the transference
that will unfold over time, and the client’s ability to internalize the thera-
pist as a caring other. What transferences emerge? What interpersonal
dynamics unfold between client and therapist in sessions? Can the client
imagine the therapist thinking of him or her positively?
How does the individual self-soothe, or respond to the therapist’s sooth-
ing? Soothing implies vulnerability and it may lead to scathing self-criti-
cism or sarcasm aimed at the therapist. If a parent required caretaking,
soothing may be linked to past burdens and neglect. If abuse was delivered
in the context of nurturance, even verbal soothing may be terrifying. The
therapist’s job is to work with the client to understand the unique historical
and current meanings.
Cognitivehehavioral work. In part, this is a process of developing
positive internal self-talk. Who in the client’s current (or past) world may
be drawn upon as a positive internal presence? The suggestions will
ideally come from the client as the therapist raises the question. It may be
a friend, a pet, the therapist, an imaginary other, or an older, wiser image
of the client, the client’s “future self.” In group therapy, we sometimes
suggest that individuals “take the group with” them to difficult encounters
(with family members, at medical appointments, and so forth). Group
members have reported imagining the group seated nearby and drawing
upon that presence at tough moments.
Client and therapist may decide to use guided imagery to create a
protected place (Brown & F r o m , 1986) where the client can spend time
with the benevolent other. The client may use the imagery of his or her
adult self comforting and protecting the child self as part of this process.
The therapist may invite the client to notice what kind of responses
from both real and imagined others feel supportive. When is a gentle
response needed? When is reassurance helpful? If sarcasm or criticism
emerges, why now? What responses are helpful? As with all cognitivehe-
havioral interventions, it is important for the therapist to check in with the
client after devising the intervention and again from time to time to see
how it is working and to fine tune where necessary.
Ability to Maintain Sense of Selfas Wable,Benign, and Positive
Exploratory work. Here too we begin with an assessment aimed at
establishing where the client is on the continuum of developmental possi-
bilities on this dimension. Clients who are not certain they exist are not
 Laurie Anne Pearlman 19

ready to work on a positive sense of self. We currently conduct this

assessment by listening to clients’ language about themselves, especially
when they are stressed. Clients who do not feel viable may say things like,
“I’m not entitled to be,” “I just shouldn’t exist,” or “Sometimes I can’t
tell whether I’m alive.” Others, who are struggling with the issue of
benign self, may have a sense of toxicity: “Everyone I get involved with
gets hurt,” or “I can’t make anything turn out right.” Finally, people in
whom this self capacity is more developed may feel that they are bad and
unworthy of anything positive. Statements reflecting this level of develop-
ment include “I don’t deserve to be happy,” “If my own mother molested
me, how could anyone else like me?”
The clinical approach here is first to understand the client’s fears about
existing, experiences of self-cohesiodself-disintegration,and history of
feelings and beliefs related to self-worth. What precipitates feelings of
shame, harsh self-criticism, self-loathing, dissociation? When these expe-
riences occur in therapy sessions, the therapist invites the client to notice
and helps him or her to name and explore with comments like, “What just
happened?” and “Let’s try to understand what might have been going on
for you before that.” The therapeutic work is to make connections among
these psychobiological states, the triggers in the present, and the past.
This work will include an exploration of the protective value of these
feelings as well. Each state (shame, dissociation, etc.) represents an
adaptation to psychological problems in the past; it also serves to protect
the individual from something in the present. For example, shame may
protect the individual from grief, intimacy, rage, or acknowledging the
parents (if they were perpetrators or passive bystanders) as malevolent or
neglectful.
Cognitivdbehavioral work. The interventions here follow the results of
the assessment. For most survivors, shame is a core issue. Shame may be
particularly problematic for those working to maintain a sense of self as
viable. The therapist must be able to name shame as a common experience
while showing continuing respect for and connection with the client.
Using Beere’s (1 989) framework for understanding shame, clients may
find it easier to talk about feeling inferior and disconnected than to talk
about shame.
Some conceptualizations of shame emphasize the element of control
(e.g., K a u f m , 1985; Stone, 1992). The childhood experience of abuse is
one of complete helplessness against shame, humiliation, and exploitation,
so it is natural that control may be supremely important to that person in
subsequent years. In addition, dissociation, which develops to protect
20 JOURNAL OF EMOTIONAL ABUSE

individuals, may also be experienced as an uncontrolled phenomenon,

adding to the survivor’s feelings of shame.
The therapist may help the client explore attributions about traumatic
experiences. Clients may feel that the abuse or some part of it was their
fault. This belief must not be challenged directly (“Of course it wasn’t
your fault”); doing so may move the client to defend, and thus become
more entrenched in this belief, and/or she may feel the therapist doesn’t
really understand her. Instead, our approach is to empathize (“I under-
stand you feel that way”), and only gently challenge (“I guess I don’t ”se
it that way” or “I don’t think children are responsible for adults’ actions,
but I understand you feel responsible”).
Clients who are working on experiencing self as benign may benefit
from reviewing self-statements about their own self-worth. The therapist
will help clients not personalize and overgeneralizewhat others say to and
about them. The therapist may encourage the client to speculate about
possibilities in others’ words beyond criticism of the client.
With people who are working on experiencing themselves as worthy or
positive, the work will focus on helping them value themselves. Identify-
ing talents and strengths can be enormously healing. The process of self-
examination is useful, as well as the task of considering valuing oneself.
The therapist must be careful not to engage the clients’ habitual devalua-
tion of themselves (T: “YOUmanage your daughter so well”; C: “No I
don’t’’). A less direct approach may be easier for the client to tolerate (T
“Your daughter seems to feel loved and cared for by you”). This is also a
building block in the therapeutic relationship; clients experience the thera-
pist as someone who encourages them to find the positive within them-
selves rather than as another critic.

A biliw to Experience, Tolerate, and Integrate Strong Feelings

For individuals who have not been in a relationship that was safe
enough to experience feelings, the thought of feeling anything can be
frightening. Therapy can provide a holding environment within which
people may begin to experience feelings for the first time in many years.
The survivor’s caution about feeling is warranted, not only because the
feelings may be strong and painful, but because s/he may not have the
ability to tolerate them as yet. Feeling is dangerous when one responds
with dissociation or self-destructive behaviors. Affect regulation is essen-
tial to enduring the feelings that will arise as clients know their history
ever more clearly and come to terms with the losses it represents. They
may experience vulnerability, shame, terror, rage, and grief.
It is important to set appropriate expectations about affect. Survivor
 Laurie Anne Pearlman 21

clients may expect that, as a result of therapy, they will no longer feel
upset, hurt, angry, or disappointed. They need to learn that painful feelings
are a natural part of human experience. The individual may choose to
remain disconnected from others in order to try to minimize disappoint-
ment and betrayal. But once they bring their dissociation under control and
stop numbing feelings, such separation will likely invite feelings of loneli-
ness and yearning. The goal of this aspect of the work is not to erase
feelings but for survivors to become acquainted with the whole range of
human feelings and to know and understand their own.
Explorutoly work.The work here focuses on exploring the meanings of
strong affect to victims and survivors. How did they survive the abuse?
Dissociation or self-harming behaviors may have begun in early child-
hood. These strategies are very effective in minimizing certain affects in
childhood, but they do not allow the individual to develop other ways of
managing feelings. What are the meanings of affect to this person? Sad-
ness may be equated with vulnerability to abuse, anger with violence. If,
for example, a client experienced her mother as nonprotective and weak,
she may now identify with her mother when she feels vulnerable, and
experience herself as loathsome.
What is this client’s affective style? Is she someone who never feels
anything, or someone for whom every moment is one of intense affect? If
the former, when did the feelings stop? What are the natural affective
pathways for this client? Does needing lead to shame? Fear to sexual
arousal (a link beautifully explicated by Davies and Frawley [1994])?
Anger to dissociation? By naming these processes as they emerge in
sessions, the therapist helps clients understand and begin to track their
own patterns.
With clients who fear feeling, what are the specific fears? They may fear
being overwhelmed or disintegrating. They may fear punishment or sim-
ply experience terror. They may think if they cry, they will never stop, or
they may fear going crazy. What does “going crazy” mean to clients who
express this fear? This expression often refers to out-of-control behavior.
What are the past events that engendered these meanings for this individ-
ual?
Clients who experience every situation with intense affect may find it
helpful to understand their own feeling history, including what they
observed and believed about strong feelings as children. Which feelings
are not experienced by this person? Are the intense feelings protecting the
survivor from other, more aversive, feeling states, thoughts, or memories?
Therapists may find these clients easier to understand within the psycho-
biological framework offered by van der Kolk (1994). He describes the
22 JOURNAL OF EMOTIONAL ABUSE

psychophysiological process through which any affect experienced by a

childhood trauma survivor may be magnified and experienced as intense.
Work on affect regulation will bring the therapy again to the exploration of
the meanings of self-soothing, discussed above in the section on maintain-
ing a sense of connection with loving others.
Cognitivebehuviorul work. The client may need to learn to recognize
and name feelings. This may mean helping sort out responses to various
situations, including the perceived threats and the other possible nuances
of a situation, and then examining responses in light of what was actually
happening interpersonally and making connections to the past. Some of
these examples will come from the individual’s interactions with others;
many will come from the relationship between therapist and client. Man-
aging these situations therapeutically requires a good deal of awareness on
the part of the therapist of the complex transference/countertransference
dynamics of psychotherapies with childhood abuse survivors (Davies &
Frawley, 1994; Lindy & Wilson, 1994; Pearlman & Saakvitne, 1995a).
Therapists will help survivor clients to differentiate among feeling bad,
going crazy, and disintegrating. They will help survivors distinguish
between feeling and acting, between anger and violence, between feeling
and dying.
Initially, the therapist may need to provide language for feelings. Direct-
ing the person to notice bodily states as a link to feelings is useful (“What
are you aware of in your body now? I wonder what emotion name might
go with that state?”).
Inviting the client to notice feelings and needs during the therapy ses-
sion offers an opportunity to reflect upon inner experience with the thera-
pist’s help. Asking clients what they will be needing at the end of a session
conveys the message that they have needs, the needs are important, and
they can learn to meet them. It also requires noticing feelings, the under-
pinnings of needs.
How does the individual now cope with strong feelings? How are these
methods effective? What are the costs? Developing affect regulation for
some clients includes learning to spend time alone. This may need to be
brief and structured at first. Many people are soothed by solo activities,
such as listening to music, painting, reading, gardening, or being in nature.
Journal-writing, creative endeavors such as drawing and crafts, and activi-
ties that connect individuals with their bodies, such as exercise, yoga, and
massage, can be helpful as they learn new ways to respond to their own
psychobiological states.
Behavioral management techniques such as the use of time out, inter-
p a o n a l skills work (such as Linehan’s [1993] skills training model or
 Laurie Anne Pearlman 23

couples or family therapy), and assertiveness and anger management train-

ing are helpfhl for some victims and survivors. The process of identifying
and managing feelings is complex and highly personal. Planned activities
such as those listed above may help clients tolerate feeling. Developing
activity ideas together provides a concrete shared task for the client and
therapist. The ideas may help the survivor invoke the caring of the thera-
pist when feelings arise outside of the therapy. There is a path toward
recovery for survivors, and the self-aware therapist can be an excellent
guide and companion on that path. Traveling this path delivers rich
rewards to survivors who are reclaiming their lives and to the therapists
who have the honor of accompanying them on the journey.

NOTES
1. Dissociation, the separation of mental contents, is one of the common
sequelae of childhood sexual abuse (Neumann, 1994; Polusny & Follette, 1995;
Pumam, 1989).
2. Research is currently underway to operationalize and measure the self
capacities (Pearlman & Deiter, 1996). Readers may obtain copies of the Inner
Experience Questionnaire by sending a self-addressed stamped envelope to the
author with a request for the scale.

REFERENCES
American Psychiatric Association (1 994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, D.C.: Author.
Beere, D. (1989, August). The experience of shame and traumatization. Paper
presented at the 97th Annual Convention of the American Psychological
Association, New Orleans, LA.
Black, A.E., & Pearlman, L.A. (in press). Self-esteem as a mediator between
beliefs about self and beliefs about others. Journal of Clinical and Social
Psychology.
Bowlby, J. (1 988). A secure base. New York: Basic.
Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary
Ainsworth. Developmental Psychology, 28(5), 759-775.
Briere, J. (1 992). Child abuse trauma: Theory and treatment of the lasting efsects.
Newbury Park, CA: Sage.
Brown, D.P., & Fromm, E. (1 986). Hypnotherapy and hypnoanalysis. Hillsdale,
NJ: Lawrence Erlbaum Associates.
Calof, D.L. (1995a). Chronic self-injury in adult survivors of childhood abuse
(Part I). Treating Abuse Today, 5(3), 1 1 - 1 7.
Calof, D.L. (1995b). Chronic self-injury in adult survivors of childhood abuse
(Part 11). Treating Abuse Today, 5(4/5), 31-36.
24 JOURNAL OF EMOTIONAL ABUSE

Davies, J.M., & Frawley, M.G. (1994). nearing the adult survivor of childhood
sexual abuse: A psychoanalytic perspective.New York: Basic.
Deiter, P.J., & Pearlman, L.A. (in press). The evaluation and management of
self-injurious behavior. In P.M. Kleespies (Ed.), Emergency psychological ser-
vices: The evaluation and management of life-threatening behavior. New
York: The Guilford Press.
Gamble, S.,Pearlman, L.A., Lucca, A.M., & Allen, G.J. (1994, October). Vicari-
ous traumatization and burnout among Connecticutpsychologists: Empirical
findings. Paper presented at Annual Meeting of the Connecticut Psychological
Association, Waterbury, CT.
Fromm-Reichmann, F. (1 960). Principles of intensive psychotherapy. Chicago:
The University of Chicago Press.
Kaufman, G. (1 985). Shame: The power of caring. Cambridge, MA: Schenkman.
Kohut, H. (1977). The restoration of these$ New York International Universities
Press.
Lindy, J.D., & Wilson, J.P. (Eds.) (1994). Countertransferencein the treatment of
PTSD. New York: Guilford.
Linehan, M.M. ( 1993). Cognitive-behavioraltreatment of borderline personality
disorder,New York: Guilford.
Mahler, M.S., Pine, F., & Bergman, A. (1975). m e psychological birth of the
human infant: Symbiosis and individuation.New York: Basic.
Mahoney, M.J. (1981). Psychotherapy and human change process. In J.H. Harvey &
M.M. Parks (Eds.), Psychotherapy research and behavior change @p. 73-122).
Washington, DC: American Psychological Association.
Mahoney, M.J., & Lyddon, W.J. ( I 988). Recent developments in cognitive
approaches to counseling and psychotherapy. Counseling Psychologist, 16(2),
190-234.
McCann, I.L., & Pearlman, L.A. (1990). Psychological trauma and the adult
survivor: i'heoty, therapy, and transformation.New York: Brunner/Mazel.
Mennen, F.E., & Meadow, D. (1 994). A preliminary study of the factors related to
trauma in childhood sexual abuse. Journal of Family Violence,9,125-142.
Miller, D. (1 994). Women who hurt themselves: A book of hope and understand-
ing. New York: Basic Books.
Neumann, D.A. (1 994). The long-term correlates of childhood sexual abuse in
adult survivors. In J. Briere (Ed.), Assessing and treating victims of violence,
pp. 29-38. San Francisco: Jossey-Bass.
Pearlman, L.A., Deiter, P.J. (1 996, November). The impact of psychological
trauma on serf capacities: Theoretical and research perspectives. Paper pre-
sented at the annual meeting of the International Society for Traumatic Stress
Studies, San Francisco, CA.
Pearlman, L.A., & Saakvitne, K.W. (1995a). Trauma and the therapisl: Counter-
transference and vicarious traumatizalion in psychotherapy with incest survi-
vors. New York: W.W. Norton.
Pearlman, L.A., & Saakvitne, K.W. (1995b). Treating therapists with vicarious
traumatization and secondary traumatic stress disorders. In C.R. Figley (Ed.),
 Laurie Anne Pearlman 25

Compassionfatigue: Coping with secondary traumatic stress disorder in those

who treat the traumatized (pp. 150- 177). New York: Brunner/Mazel.
Piaget, J. (1971). Psychology and epistemology: Towards a theory of knowledge.
New York: Viking.
Polusny, M.A., & Follette, V.M. (1995). Long term correlates of child sexual
abuse: Theory and review of the empirical literature. Applied and Preventive
P~~chology, 4, 143- 166.
Putnam, F.W. (1 989). Diagnosis and treatment of multiple personality disorder.
New York Guilford.
Rotter, J.B. ( 1954). Social learning and clinical psychology. Englewood Cliffs,
NJ: Prentice Hall.
Rotter, J.B. (1982). The development and application of social learning theory.
New York: Praeger Publishers.
Saakvitne, K.W. (1992, August). Incest and feminine identity: Shame, sexuality,
and rage. In K.W. Saakvitne(Chair), Unconsciousshame, guilt, and psychoan-
alytic considerations of trauma. Symposium conducted at the annual meeting
of the American Psychological Association, Washington, D.C.
Stone, A.M. (1 992). The role of shame in post-traumatic stress disorder. American
Journal of Orthopsychiatry,62( l), 13 1- 136.
Sullivan, H.S.(1953). The interpersonal theory ofpsychiatty. New York: Norton.
van der Kolk, B.A. (1994). The body keeps the score: Memory and the evolving
psychobiology of posttraumatic stress. Harvurd Review of Psychiatry, 1-6,
253-265.
van der Kolk, B.A. (1996). The complexity of adaptation to trauma: Self-regula-
tion, stimulus discrimination, and characterological development. In B.A. van
der Kolk, A.C McFarlane, & L. Weisaeth (Eds.), Truumatic stress: The eflects
of overwhelming experience on mind, body, and society (pp. 182-213). New
York: The Guilford Press.
White, M.T., 8i Weiner, M.B. (1 986). The theory and practice of self-psychology.
New York Brunner/Mazel.
Wilson, J. P., & Lindy, J. (Eds.). (1 994). Countertransference in the treatment of
PTSD. New York: Guilford.
Winnicott, D. W. (1965). The maturational process and the facilitating envimn-
ment: Studies in the theory of emotional development. New York: International
Universities Press.
Wong, M.R.,& Cook, D. (1 992). Shame and its contribution to PTSD. Journal of
Traumatic Stress, 5(4), 557-562.

SUBMITTED:0 I/ 13/96
REVISION SUBMITTED: 07/22/96
REVISION SUBMITTED: 10/10/96
ACCEPTED: 12/23/96