Improving mental wellbeing for survivors of childhood abuse and neglect: psychological healing and education course in prisons

Common Problems

Key texts informing the development of NAPAC’s approach were self-help books for survivors first published in the USA: The Courage to Heal ¹ for females and Victims No Longer ² for males. Both texts encouraged adult survivors to work through their problems at their own pace and explained many of the issues survivors face in adulthood. Some of the problems described include:

Dr Judith Lewis Herman ³ of Harvard Medical School brought rigorous academic analysis to the topic in Trauma and Recovery: The Aftermath of Violence by comparing the consequences of trauma on three social groups: domestic violence victims, military personnel injured in combat and adult survivors of sexual abuse during childhood. Herman identified significant differences in the long term sequelae between these groups due to such factors as early age of onset, number of traumatic events and number of perpetrators and public recognition of the reality of the trauma. The consequences of sexual abuse during childhood were shown to be far more complex and difficult to address than combat trauma, for example, partly because the general public is less likely to believe a child’s account than that of an adult member of the armed services engaged in action widely reported in the news media. For these and other reasons, Herman identified the concept of complexity in post-traumatic stress disorder (PTSD), which means that simple interventions such as cognitive behavioural therapy are less likely to be effective with survivors of childhood abuse than with personnel wounded in combat. Recovery from childhood trauma takes more time and harder work with more support than simple PTSD. Coping mechanisms learned in childhood may become deeply embedded through adulthood and therefore hard to replace; memories may have been repressed by the child and stored subconsciously causing a range of mental and physical problems.

Such understanding has now become widely accepted by practitioners:

The traumatic stress field has adopted the term complex trauma to describe the experience of multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset. ⁴

More recently, the UK Government commissioned the Victims of Violence and Abuse Prevention Programme overseen by the late Dr Catherine Itzen, a very large scale assessment of the problem. Their report summarises the situation as follows in their introduction:

Domestic and sexual violence and abuse affects a very substantial minority of the population. It is largely women, and children of both sexes, who are affected, but men are also raped and experience domestic violence. Child physical, emotional or sexual abuse and neglect and domestic violence are causal factors in the mental and physical ill-health of children, adolescents and adults and affect a significant proportion throughout their lives. The high costs in prevalence and economic burden on health and social care services and the criminal justice system have pushed these issues up the policy agenda. ⁵

While it is important to remember that the vast majority of adult survivors of childhood abuse and neglect never come into contact with the criminal justice system, it is clear that some do. There is a wide range of discussion of possible causalities and scales in the literature. Some examples are given here:

Complex trauma exposure results in a loss of core capacities for self-regulation and interpersonal relatedness. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and cumulative impairment (e.g. psychiatric and addictive disorders, chronic mental illness, legal, vocational, and family problems). ⁶

The results of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Field Trial suggested that trauma has its most pervasive impact during the first decade of life and becomes more circumscribed (i.e. more like ‘pure’ PTSD) with age. The diagnosis of PTSD is not developmentally sensitive and does not adequately describe the effect of exposure to childhood trauma on the developing child. Because infants and children who experience multiple forms of abuse often experience developmental delays across a broad spectrum, including cognitive, language, motor, and socialization skills, they tend to display very complex disturbances. ⁴

We find that maltreatment approximately doubles the probability of engaging in many types of crime. Low socio-economic status children are both more likely to be mistreated and suffer more damaging effects. Boys are at greater risk than girls, at least in terms of increased propensity to commit crime. Sexual abuse appears to have the largest negative effects, perhaps justifying the emphasis on this type of abuse in the literature. Finally, the probability of engaging in crime increases with the experience of multiple forms of maltreatment as well as the experience of Child Protective Services (CPS) investigation. ⁷

… most of the girls who were sexually abused, like their non abused peers, did not have an official record of delinquency or adult criminality. In fact, contrary to expectations, victimization status was not associated with juvenile arrests in general. The hypothesized relationship was confirmed, however, for adult offending: sexual abuse victims were significantly more likely to have been arrested as adults than their matched counterparts even after controlling for a childhood history characterized by family problems serious enough to have resulted in a dependency hearing. ⁸

Focusing on Recovery

The four quotes above illustrate the problems some survivors may face in adulthood and some of the inherent difficulties associated with working with such people. Some adults can spend years and thousands of pounds in intensive psychotherapy working on these issues, so a 12-session course cannot be expected to bring full recovery. Rather, the objective is to provide attendees with a tool-kit of techniques and a level of self-awareness that enables the survivor to begin taking charge of their own recovery while drawing on support through the NAPAC support line. Gwen Adshead ⁹ points out that we should have a broadly optimistic outlook on the prognosis for PTSD sufferers: ‘Recovery is the norm, but may be delayed where there is further stress’. In cases of complex PTSD experienced by adult survivors of childhood abuse and neglect, this delay has already gone on for years or decades. But it should be remembered that recovery is what most people want, even if they cannot believe it is possible. The methodology of the NAPAC Way Out course draws on the work of the Trauma Recovery Group. ¹⁰ Although based on a feminist perspective, this approach, developed over 25 years of continued refinement, leads to an egalitarian empowerment applicable to both male and female adult survivors of childhood sexual abuse. The guide starts by saying,

Group therapy provides the survivor of interpersonal violence with unparalleled opportunities to combat social isolation, connect with sources of resilience and self-esteem, and rebuild relational capacities. ¹⁰

They go on to say,

By providing a safe and structured relational context for healing, group therapy provides a unique opportunity to restore social connections while also addressing the deleterious impact of interpersonal trauma on the survivor’s experience of self in relationships. ¹⁰

These authors also provide a thorough review of the range of therapeutic practices commonly used to address complex PTSD which they assess in three broad categories: supportive, cognitive-behavioural and psycho-dynamic. Their assessment of the respective advantages and disadvantages of these techniques, combined with practical experience, has led them to synthesise a ‘stage-based’ approach to working with adult survivors which refers back to Herman ³ and others. They advocate a time limited and structured course of group work as described in their manual: ‘in order to contain the emotional intensity of trauma-focused work and provide an impetus for pursuing and achieving short-term goals related to the broader task of recovery’. ¹⁰

Herman ³ identified five distinct stages in the recovery process:

Much of this can be addressed in a custodial context, but the absence of social connections may remain a problem until release. Some potential attendees may have lost all prior social connections but might be able to re-establish relationships using tools acquired through the Way Out course. Many texts highlight the importance of having a safe environment in which to conduct this difficult personal work^{1 –3} which may be hard to achieve in prisons. For this reason, it is important that selection criteria for participation in the course ensure the inclusion of suitable attendees. Van der Kolk ¹¹ describes the main selection criteria for participation in group work addressing childhood trauma:

The most important issue we evaluate is the capacity of our patients to modulate their affective arousal: whether they are able to be emotionally upset without hurting themselves, becoming aggressive, or dissociating. As long as they cannot do this, addressing the trauma is likely to lead to negative therapeutic outcomes. Similarly, as long as they dissociate when they feel upset they will be unable to take charge of their lives and will be unable to ‘process’ traumatic experiences. Hence, a substantial part of the treatment of our chronically traumatised patients consists of stabilization and the development of resources to cope with both the sequelae of their earlier trauma and with the challenges of day-to-day life. ¹¹

Dissociation is a common coping mechanism used by abuse survivors^1–3 and may be even more widely used by survivors in a custodial situation where there is little stimulation or social interaction. The selection process for attendees will have to make allowances for this while maintaining a view of the sustainability of the group as a whole. NAPAC does not work with survivors who have themselves become perpetrators of sexual violence in adulthood. NAPAC recommends referral to Stop it Now (http://www.stopitnow.org.uk) for such people. If group work in prisons brings out information that an attendee has become an active threat to the safety of children, such information must be forwarded to police and social services. This is a departure from the usual rules of confidentiality in a professional therapeutic relationship which is necessary in the prisons context. Attendees must be made aware of this and agree to it.

NAPAC – The Way Out course

Over the last decade, NAPAC has developed and refined a structured approach to working with survivors of childhood abuse and neglect which can start from the point of first disclosure. The first few sessions address the four problems outlined in the bullet points above, and further sessions go on to address shame and exploring the negative coping mechanisms survivors may have used. This progresses through development of an awareness of the reasons why negative and possibly destructive coping mechanisms were used by the survivor and acknowledging that such unconscious actions enabled the traumatised child to survive. This then puts the attendee in a position to see that they have some agency and choice in their own coping mechanisms so that more constructive ways of thinking about themselves and others can be developed. The Way Out course has empowerment and self-awareness as targeted outcomes. The Way Out course gives attendees some tools to help them understand their own behaviour and to cope more constructively, examples of positive coping mechanisms are drawn out in group work and on-going support is provided through NAPAC’s support phone line (free of charge). Most survivors would naturally like to find a life free from the problems caused by the actions or neglect of others, but are intimidated by the scale of their problems. The Way Out course has been shown to be of great help in empowering attendees to meet this challenge (testimonies are available).

Some of the techniques attendees are encouraged to develop include ‘grounding’, ‘self-compassion’ and ‘mindfulness’. ‘Grounding’ includes a set of techniques to help cope with panic attacks and intrusive memories, for example, by focusing on the breathing. Self-compassion and mindfulness are concepts developed by Professor Paul Gilbert ¹² at University of Derby (and others such as Neff ¹³ ) to structure an approach to working with shame, an issue many abuse survivors struggle with.^1–3 For example, attendees are encouraged to see their early coping mechanisms as having served a purpose in enabling them to survive childhood trauma, although there may have been negative impacts associated with such behaviour. Self-compassion in this context is not confused with self-pity or self-indulgence; ¹³ rather, it is an important part of the development of the attendee’s self-awareness. All of these methods help the attendee gain conscious agency over their future life choices.