When I was a child, I spoke as a child, I understood as a child, I thought as a child: but when I became (an adult) I put away childish things. For now we see through a glass darkly; but then face to face: now I know in part; but then shall I know even as also I am known. The Bible: I Corinthians 13:9-13.
The biblical passage quoted above, reflects one of the major premises of our work: that trauma survivors often view themselves and the world as if through a glass darkly, a psychological experience in which inner i representations of self and world are disrupted, coloring all future perceptions. An understanding of the unique inner, experience of sur- vivors is essential as helpers guide the survivor gradually to transform these disrupted representations of self and world into a new reality that is both adaptive and positive. In this book, we present a new conceptualization of the unique experience of trauma survivors. We offer both a new theoretical model which we call constructivist self development theory (CSDT) and a description of its application to clinical assessment of and intervention with adult trauma survivors. Constructivist self development theory focuses on the interaction between the person and the situation, with partictilar focus on the self in development. Our work integrates a number of theoretical and empirical contributions by many who have studied both trauma and self development and is based in a constructivist perspective (Mahoney, 1981). Initially, theorists attempted to understand responses to trauma by focusing on the individual's preexisting pathology, suggesting that those who were more psychologically vulnerable were most deeply affected. This view was widely held by psychodynamic theorists who studied war trauma among World War II veterans (e.g., Brill, 1967; Lidz, 1946). Other theorists at the time recognized that under certain conditions, all individuals were vulnerable to breakdown, and that post-trauma re- actions were related to the unique stressors of war (e.g., Grinker & Spiegel, 1945; Kardiner, 1959). Since the mid-1970s, the characteristics of the stressor have become more focal as researchers empirically validated that certain events such as the Vietnam combat experience, rape, and incest produced psychological difficulties in most individuals who were exposed to them (e.g., Courtois, 1979; Foy, Sipprelle, Rueger, & Carroll, 1984; Kilpatrick, Veronen, & Best, 1985; Laufer, Brett, & Gallops, 1985). Since the mid-1970s, numerous research reports have confirmed Freud's (1920/1953) original assertion that a traumatic event of a certain magnitude will affect almost all who are exposed to it (see S cr, field,-198,5,ar a review of these issues). The next step in the evolution of theorizing about trauma was a consideration of the person-situation interaction, a perspective that is gaining more prominence in theories of trauma (e.g., Epstein, 1985, in press a; Green, Lindy, & Wilson, 1985; Hendin & Haas, 1984; Scurfield, 1985; Wilson, Smith, & Johnson, 1985). This perspective takes into account both the individual's unique psychological development and the role of the traumatic experience itself in post-trauma adaptation. Although more complex, the interactive approach allows for a more complete understanding of unique adaptation to trauma because it can consider both the empirically demonstrated important characteristics of the event and the full complement of person characteristics beyond simply "preexisting pathology.'" Constructivist self development theory extends the interactionist tradition and, in addition, emphasizes the importance of_th individual as an active agent in creating ndLcsc struin , .his ,0_er re. alty ev-at is basic to any constructist theory (Mahoney, 1981; Mahoney & Lyddon, 1988). In relation to this evolving paradigm shift, we believe that a current challenge in the field of traumatic stress studies is to avoid the danger of depriving trauma survivors of their individuality and uniqueness by focusing exclusively on the commonalities in response patterns among survivors. We must remember that trauma is experienced by persons, not by dehumanized "victims," and that their differences, as well as their commonalities, must be respected and understood. A number of theorists have supported this basic position through theoretical and research paradigms that focus on unique persons and their psychological development (e.g., Danieli, 1985; Green, Lindy, & Wilson, 1985; Lifton, 1988; Lindy, 1988; Roth, 1989). Our hope is to extend this position to enable clinicians and researchers to develop a greater understanding of the variations and differences in human adaptation to trauma.
THE DEVELOPMENT OF CONSTRUCTIVIST SELF DEVELOPMENT THEORY
This theory has been developed within the context of our professional commitment to studying and treating survivors of a variety of traumatic events. These include rape, childhood sexual and physical abuse, war, domestic violence, other crimes, chronic illness, accidents, and other serious stressors. Within the field of traumatic stress, we view ourselves as generalists who are interested in .understanding the individual var- iations in adaptation to trauma. Our work has been a collaborative effort with our colleagues and clients at The Traumatic Stress Institute. The Institute is a private mental health organization which specializes in understanding and treating trauma survivors. Our ideas have evolved through intensive, ongoing study of the existing literature as it applies to our clinical work. We are currently involved in empirically validating our ideas with a wide variety of adult survivors. We hope these ideas will stimulate further research and the expansion of theory by other colleagues working in the field. Early in our work at the Institute, we began to see the need for a heuristic model that would integrate the literature on trauma and individual psychological development. The theory we have developed brings together many lines of thinking about trauma and provides a map that can help researchers and clinicians understand both common and unique responses to trauma. As we apply the theory to our clinical work, we continue to learn about the richness and complexity of individuals' experiences of trauma. This in turn leads to revisions in the theory which lead us to a deeper understanding of our clients and their healing processes.
THE IMPORTANCE OF THEORY
A theory, like a map, provides a framework for exploration. Theory provides a way of understanding pieces of an individual's experience which otherwise might seem unrelated (see Rotter, 1954, on the im- portance of theory in clinical psychology). It allows the therapist to make connections, to know what else to look for, and to help the client develop ways of understanding his or her experience. Such a map allows the therapist to put the individual trauma survivor's experience in context and to guide him or her in exploring and resolving all aspects of it. Even without a map, the explorer may be fortunate enough to take the necessary turns that will lead through the healing process. However, there are many pitfalls that may be encountered along the way, posing risks to both client and therapist. We believe that a map, or a comprehensive framework, enables the clinician to navigate the journey in a way that is most beneficial for the trauma survivor. While no map can be an exact guide to any individual's experience, the theory we present here has enabled us to lead our clients gently through rocky terrain toward healing and it has contributed to our own growth as clinicians.
Here we provide a brief overview of the theory that will be elaborated in subsequent chapters in this book. We propose that adaptation to trauma is a result of a complex interplay between life experiences (including personal history, specific traumatic events, and the social and cultural context) and the developing self (including self capacities, ego resources, psychological needs, and cognitive schemas about self and world). The experience of trauma begins with exposure to a non- normative or highly distressing event or series of events that potentially disrupts the self. The individual's unique response to trauma is a complex process that includes the personal meanings and images of the event, extends to the deepest parts of a person's inner experience of self and world, and results in an individual adaptation. The major underlying premise of constructivist self development theory is that individuals possess an inherent capacity to construct their own personal realities as they interact with their environment. This constructivist position asserts that human beings actively create their representational models of the world (Epstein & Erskine, 1983; Mahoney, 1981; Mahoney & Lyddon, 1988). Continuing psychological development depends upon the evolution of increasingly complex and differentiated psychological systems. We are interested here in three major psychological systems: (1) the self (or the individual's sense of himself or herself as a knowing, sensing entity, complete with capacities to regulate self-esteem and ego resources to negotiate relationships with others); (2) psychological needs (which motivate behavior); and (3) cognitive schemas (or conceptual frameworks for organizing and interpreting experience). This aspect of the theory draws upon and is consistent with a number of theoretical perspectives, including developmental object relations theory (Mahler, Pine, & Berg-
man, 1975), Kohut's (1971) self psychology, and Epstein's (1985, in press b) cognitive-experiential self-theory. These systems evolve over the course of the life span. As persons grow and develop, they assimilate or incorporate more and more of the surrounding environment into their existing schemas for experience or conceptual frameworks. In object relations terms, these schemas are equivalent to mental representations of self and others. The processes whereby such changes take place are accommodation and assimilation, first described in Piaget's cognitive developmental theory (Piaget, 1971). When the environment presents new information that cannot be assim- ilated into existing schemas, cognitive schemas are modified, a process called accommodation. The complex interplay and balance between accommodation and assimilation results in the increasing differentiation and maturation of the psychological systems. We refer to this growth as progressive self development. Trauma, by definition, requires accommodation, or a modification in schemas. Because the trauma-induced disruptions are, again by defi- nition, in psychologically central areas, the accommodation process is difficult. Thus, trauma disrupts, at least temporarily, the individual's psychological growth. All experience is encoded in the memory system, with the imagery system of memory (Paivio, 1986) associated with strong emotions and other vivid sensory impressions. The return of these traumatic images is one of the hallmarks of the post-trauma experience (Brett & Ostroff, 1985). The reexperiencing of traumatic imagery is very painful and disruptive, creating a defensive tendency to avoid this material. The processes of reexperiencing and denial were first described by Freud (1939/1964), later elaborated by Horowitz (1979, 1986), and most recently described within an approach-avoidance paradigm by Roth and Cohen (1986). We extend this thinking to include the notion that the return of traumatic imagery is so painful because it challenges the self resources and capacities and disrupts the psychological needs and cognitive sche- mas about self and world. The individual is faced with the task of assimilating the meanings of the trauma into existing schemas, and/or accommodating or changing schemas to integrate a new reality. Indi- viduals often attempt to avoid the process of accommodation because the transformation of inner models of self and world is extremely disruptive psychologically. The previous developmental history of the individual, including the evolving sell needs, and schemas, will shape what is remembered about the trauma and how the event is experienced and interpreted. The process of healing and transformation must ulti- mately result in renewed developmental progression, a process in which the self-capacities and resources are strengthened, psychological needs are balanced, and schemas are adjusted to incorporate new information in a way that enables the individual to experience pleasure and sat- isfaction in his or her life.
THE BOOK: AN OVERVIIW
The theory we have sketched above will be described in detail in the chapters that follow. Chapter 2 presents our model of individual psychological development; here we describe our understanding of the self, psychological needs, and schemas. We also describe the experience of trauma, focusing particularly on the imagery system of memory, corresponding emotional experiences, and the way in which schemas color what is remembered about the trauma. Ch/pter 3 presents data regarding the prevalence and incidence of victimization, a synthesis of current theories of trauma, and a review of research findings regarding the commonalities in response patterns across traumatic events. While we cannot fully review the many useful theories of trauma that have emerged over the past 15 years, Chapter 3 provides a context for understanding how our own theory integrates and extends insights from many others. We elaborate upon disruptions in cognitive schemas in Chapter 4. This chapter provides a theoretical context for understanding the pow- erful impact of schemas on the individual's interpretation of and unique adaptation to trauma. The following six chapters relate to clinical as- sessment and intervention. In Chapter 5, we provide an overview of adaptation to trauma and a general framework for clinical assessment and intervention with survivors. Chhpter 6 begins by providing a framework for assessing and un- derstanding the important impact of life experiences as they are per- ceived by the survivor, including personal history, characteristics of the trauma, and the social and cultural context within which trauma occurs. Chapter 7 describes the reparative self work that is essential for many trauma survivors in order to enable them to regulate self-esteem and tolerate the painful work involved in memory integration. Although we draw upon thinking from self psychology theory (Kohut, 1971, 1977), our intent is to present our distillation of these concepts in a way that is understandable for clinicians without a specific background in self psychology.
Chapter 8 presents a paradigm for systematically assessing schemas that have been seriously disrupted, resulting in problems in self-world relations and other aspects of adaptation. Chapter 9 describes therapeutic interventions focused on restoring positive schemas and resolving dis- turbed schemas. Chapter 1) integrates existing knowledge about the experience of traumatic memories, with a focus on assessing verbal and imagery systems of memory as a prelude to memory integration. In Chapter 10 we also discuss resistances to recovering repressed or avoided memories and their resolution, as well as techniques for managing the emergence of distressing, intrusive imagery. The next section covers special issues. Chapter 11 focuses on un- derstanding transference reactions and ristances in constructivist self development theory terms. In Chapter 12 we discuss the application of the theory to such special issues as self-destructive behaviors, affective disturbances, and interpersonal difficulties. Next, we review findings related to different treatment modalities, including crisis management, group, family, and couples therapy, and finally, pharmacological inter- ventions. In Chapter 1 we focus on special populations, including survivors of childhood trauma, victims of violence and other traumas in adulthood, survivors of historical or cultural traumas, and persons exposed to life-threatening illness. In this chapter, we synthesize im- portant insights from previous research and interpret these findings in constructivist self development theory terms in the hope of shedding new light on these populations. Finally, in Chapter 14, we describe four cases in depth by system- atically applying the theory to assessment and treatment of survivors with unique styles of adaptation. Because it attempts to be comprehensive, this theory is complex. Our hope is that we have presented it in enough detail that it can serve as a map for others. 2. Constructivist Self Development Theory
This chapter presents our thinking about self development, including the interconnected aspects of the self (self capacities, ego resources, psychological needs, and cognitive schemas) and the encoding of trail- matic experiences in memory. The theory is interactive--that is, it focuses on the complex interaction between person and environment, an increasingly common view in the trauma literature. Figure 1 depicts the psychological experience of trauma as understood through this complex person-situation interaction. While constructivist self develop- ment theory acknowledges the great importance of the psychological situation (described by Rotter  as the individual and his or her meaningful environment), like other interactive theories, it has yet to articulate the way in which specific aspects of situations elicit particular schemas, feelings, needs, and so forth, from individuals. This is part of the future work of developing the theory and testing its hypotheses empirically. We first provide a working definition of trauma, based upon our theory. We then present the basic tenets of the theory.
DEFINITION OF TRAUMA
We define psychological trauma as follows: An experience is traumatic if it (1) is sudden, unexpected, or non-normative, (2) exceeds the individual's perceived ability to meet its demands, and (3) disrupts the individual's frame of reference and other central psychological needs and related schemas. The first part of the definition serves to exclude the chronic difficulties of life, which, although themselves important and at times severe, must be distinguished from trauma if the construct is to serve any heuristic purpose, as Anna Freud (1967) and Henry Krystal (1978) have pointed out. Our definition includes experiences which may not be unexpected for the individual, such as ongoing incest, but which, from the perspective of the larger society, are non-normative. The second part of our definition is consistent with Richard Lazarus's (1966) transactional model of stress. He defines stress as the discrepancy between the demands of the situation and the individual's perceived ability to meet those demands. He thus squarely places "stress" into the realm of the psychological; it is our intention to do so with "trauma." A recent article by Koss and Burkhart (1989) cites a statement by Lazarus and Folkman (1984) that is particularly relevant to our point of view. Koss and Burkhart state, Appraisals are influenced by both situation factors (e.g., predict- ability, duration, and ambiguity of the stressor) and person factors: that is, "commitments--what is important to the person; beliefs-- personally formed or culturally shared preexisting notions about reality which serve as a perceptual lens . . . and existential be- liefs-faith in God, fate, or some natural order . . . that enables people to create meaning out of life, even out of damaging ex- periences, and to maintain hope." (Lazarus & Folkman, 1984, pp. 58-77) (Koss & Burkhart, 1989, p. 30) In constructivist self development theory terms, to be defined later in this chapter, Lazarus and Folkman's "commitments" are equivalent to psychological needs; "beliefs" are equivalent to schemas; and "ex- istential beliefs" would be equivalent to the broadest schemas for exper- ience, those related to frame of reference. In this regard, the Lazarus and Folkman (1984) view of trauma is most similar to our own. This second portion of our trauma definition highlights our quintes- sentially constructivist view of personality. Thus, an essential part of what determines whether an experience is traumatic is the individual's sense that it is so. As will become evident in subsequent chapters, this appraisal is related to the individual's self capacities and ego resources, constructs which we define below. Finally, we emphasize the importance of individual differences in the third part of the definition. An experience is traumatic in part because it in some way threatens the psychological core of an individual. Thus, one person's trauma may be another person's difficult experience. This final part of the definition is similar to the definition of "Gross Stress Reactions," a diagnosis in DSM-I (American Psychiatric Association, 1952), proposed by Weiss and Payson (1967) who write,
Gross stress is any unusual influence or force perceived as threat- ening a vital goal or need of an individual or group. In its severest form, it brings about an insoluble conflict of vital goals or needs. (p. 1027) Note that Weiss and Payson define "gross stress" as the external force. Here we differ, defining trauma not as the stressor but as the individual's psychological response. In this we are consistent with I(rystal (1978) who describes trauma as "a paralyzed, overwhelmed state, with immobilization, withdrawal, possible depersonalization, evidence of dis- organization" (p. 90). Figley also conceptualizes trauma as the response rather than the stressor; in his excellent edited volume, Trauma and Its Wake (1985), he "use(s) the concept of trauma to represent an emotional state of discomfort and stress resulting from memories of an extraordinary, catastrophic experience which shattered the survivor's sense of invulnera- bility to harmn (p. xviii) (original italics).
CONSTRUCTIVIST SELF DEVELOPMENT THEORY: AN OVERVIEW Constructivist self development theory is a synthesis of developmental theory (Mahler, Pine, & Bergman, 1975), self psychology (I(ohut, 1977), social learning theory (Rotter, 1954), and other cognitive theories (e.g., Mahoney, 1981; Piaget, 1971). Within the trauma literature, we have also integrated concepts derived from the theories of Parson (1984), Epstein (in press a), Janoff-Bulman (1985, 1989a, 1989b), Horowitz (1986), and Roth (1989). We have taken notions from these theories and attempted to integrate them into a comprehensive personality theory which is useful to both clinicians and researchers; here we apply it specifically to understanding and treating the adult trauma survivor. The theory is, of course, open to empirical investigation and will undoubtedly continue to evolve as research data accumulate. The major features of constructivist self development theory are listed in Table 2.1. In the following sections, we attempt to discuss these notions in enough detail to provide the reader with a working under- standing of the theory. We describe these major concepts in more detail in later chapters.